The London Fire Brigade breached national guidelines by failing to adequately prepare for the Grenfell Tower fire, a damning report has concluded.
Inquiry chairman Sir Martin Moore-Bick said the LFB’s preparation for an incident such as Grenfell was “gravely inadequate”, and the absence of a plan to evacuate the tower was a “major omission”.
However, because there was no attempt to carry out a managed evacuation of the tower, the lack of a contingency plan was less significant than the absence of training to help incident commanders recognise when this might be necessary, he said.
Some of the 46 recommendations he has made require “urgent action” from the Government and others with responsibility for the “oversight and direction” of the emergency services, he said in a letter to Prime Minister Boris Johnson.
One of the groups representing bereaved and survivors, Grenfell United, welcomed the “strong” findings which “give us some confidence that our journey towards truth has finally begun”.
The report concludes that fewer people would have died had residents been evacuated while it was still possible and “serious shortcomings” not plagued the fire service’s response.
It also accuses the brigade’s commissioner, Dany Cotton, of “remarkable insensitivity” after she said she would not have done anything differently on the night.
Ms Cotton infamously told the inquiry that preparing for Grenfell would have been akin to preparing for landing a spaceship on the Shard.
But Sir Martin said her evidence “only serves to demonstrate that the LFB is an institution at risk of not learning the lessons of the Grenfell Tower fire”.
He said in a pre-recorded video message: “I consider that these represent significant systemic failings in the organisation or the LFB and show that it had failed to learn the lessons of the Lakanal House fire; but at the same time I find that, following the refurbishment, the external walls of the building did not comply with the Building Regulations because they did not adequately resist the spread of fire over them. On the contrary, they promoted it.”
Six people died in the Lakanal House fire in 2009.
Grenfell United said senior firefighters had failed to learn the lessons from the blaze and called on them to “stop hiding behind the bravery of their frontline firefighters”.
The group said: “While nothing can ever bring back our loved ones that passed away in the fire, this is a strong report with a forensic examination of the events of the night and clear recommendations that if implemented will save lives. The Government cannot afford to repeat the mistakes of Lakanal and ignore them.
“Justice means different things for all of us but the truth needs to be at the heart of our collective healing. We have been waiting a long time for this report.
“Today’s findings give us some confidence that our journey towards truth has finally begun. We now need to urgently see responsibility and action from this report, not excuses.”
In his report, Sir Martin said the principal reason the flames shot up the building so fiercely was the combustible aluminium composite material (ACM) cladding with polyethylene cores which acted as a “source of fuel”.
The report also concluded that the fire, in which 72 people died, started as the result of an “electrical fault in a large fridge-freezer” in a fourth-floor flat.
The judge said he had not intended to investigate whether the building complied with regulations at this stage, but there was already “compelling evidence” that the external walls did not.
Grenfell United said it was Sir Martin’s “most important conclusion” and raises serious questions for those involved in the refurbishment of the block.
They said: “This finding adds to our determination to see criminal charges brought against those responsible for turning our homes into a ‘death trap’.”
Sir Martin also criticised the London Fire Brigade for its “stay-put” strategy when residents were told to remain in their flats by firefighters and 999 operators for nearly two hours after the blaze broke out just before 1am.
The strategy was rescinded at 2.47am.
Sir Martin said: “That decision could and should have been made between 1.30am and 1.50am and would be likely to have resulted in fewer fatalities.”