Grenfell Tower inquiry: expert explains four main findings – and how emergency services must improve

Focus on the fire service. John Gomez/Shutterstock.

Paresh Wankhade, Edge Hill University

The long-awaited phase one report of the public inquiry led by Sir Martin Moore-Bick into the fire at the Grenfell Tower has been published. This report examines the events of an extremely complicated situation on the night of June 14, 2017, which resulted into the tragic loss of 72 lives. It investigates the cause of the fire, how it developed and the steps taken by the London Fire Brigade (LFB) and other emergency services.

Understandably, the response to the findings – which underscore failures by emergency services – has been immediate and intense, with survivors calling for the resignation of London Fire Brigade chief Dany Cotton. Yet the report runs over 830 pages, and it will take time to examine and understand the findings in detail. For now, I’ve drawn on my expertise in the management of emergency services to summarise the report’s key findings and recommendations.

1. Require owners and managers to share information about building design and materials.

Similar cladding was found on Chalcots Estate in Camden, London. mattbuck/Wikimedia Commons.

While the report was critical of the fact that LFB was unaware of the combustible nature of the materials used in the external cladding that surrounded Grenfell Tower, it concluded that the cladding was largely responsible for the fire spreading so quickly.

The report recommends that owners and managers of every high rise residential building (over 18 metres in height) should provide their local fire and rescue service with information about the design of its external walls and details of the materials of which they are constructed. This is a significant recommendation, which should help local fire services to recognise the nature of each fire they face, and make contingency plans to deal with specific types of fires.

2. Develop national guidelines for the evacuation of high rise towers.

Moore-Bick praised the firefighters who attended the tower for their extraordinary courage and selfless devotion to duty, but concluded that the absence of an operational evacuation plan was a “major omission” in the LFB’s preparation for a fire at a building such as Grenfell Tower.

The report argued in length whether the “stay put” policy – whereby tower block residents were advised to stay inside their flats, to compartmentalise the fire – could have been reviewed by the brigade earlier in the night, so that more lives could be saved. This is undoubtedly one of the most emotive and controversial issues brought up by the report.

The report also called for a legal requirement on owners and managers of every high rise residential building to draw up evacuation plans and need for contingency planning, including speakers and siren systems, to alert residents to understand the evacuation drill when needed. This may prove more difficult to implement, especially in tower blocks with single staircases. Fears for the safety of elderly people and young children in such scenarios may require the government to bring in new laws to specify planning requirements for the number of stairs and lifts.

3. Improve the response, training and communication within the fire service.

The report was critical about the response of LFB, both on the ground and in the control room where 999 calls were handled – especially regarding how information from callers was processed and shared with ground commanders. The inquiry found that senior control room staff lacked the training to manage a large-scale incident, while operational commanders lacked the training to recognise the need for an evacuation – or organise one.

The report concluded with recommendations to improve call handling and staff training, and develop better communication channels between staff on the ground and and in the control room to facilitate direct communication. It also recommended providing an integrated system of recording fire safety guidance information.

4. Strengthening cooperation between police, fire and ambulance services.

The report also identified lack of coordination between the three emergency services (the LFB, police and ambulance), particularly in the “area of communication between control rooms” and in relation to the “advice to be given to callers” trapped in the tower.

Their failure to share declarations of a major incident – which calls for extra levels of command, control and coordination between emergency services – went against protocols and hampered a joint response between police, fire and ambulance services.

What lies ahead

The report identified massive communication and command challenges for the LFB – and makes a compelling case for organisational learning across the emergency services. My own research has also identified governance challenges and a lack of coordination between emergency services – as did the Kerslake Report on the Manchester Arena tragedy of May 2017. So clearly, these are persistent problems.


Read more: How to reboot Britain’s fractured emergency services


Giving staff proper training, re-assessing the way decisions are made and undertaking rigorous risk assessments – as recommended by the inquiry – will go a long way to reassure the public about fire safety in high rise buildings, and the conduct of emergency services. But it will require additional investments in the services, which are already grappling with spending cuts.

Fire services alone have witnessed a 12% spending reduction in real terms between 2010 and 2015.
Doing “more with less” is also proving difficult for ambulance services. And central government funding to police and crime commissioners has been reduced by £2.3 billion (25%) in real-terms between 2010-11 and 2015-16.

Phase one of the report has been revealing, but the public will be in a better position to exercise judgement after phase two of the inquiry has run its course, and identified the aspects of the “design, construction and management of the building that were primarily responsible for the disaster”.

Paresh Wankhade, Professor of Leadership and Management, Edge Hill University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Searching questions need to be asked about the Grenfell Fire

Dr Howard Davis, Senior Lecturer in Criminology and Criminal Justice.

Whether in the form of a public inquiry, as announced by Theresa May on June 15th, or through an inquest, offering the possibilities of a narrative verdict by a jury, questions following the Grenfell Fire need to be searching and wide ranging. Limited inquiries often neglect broader circumstances within which conditions for disaster develop. There are obvious incentives for governments to restrict terms of reference after tragedies like this. Exploration of social, economic and political contexts within which disasters ‘incubate’ may threaten established ways of seeing and doing things. Disasters in this sense often challenge authorities, whose primary task should be to keep us safe.

‘Questions need to be answered’ has, and usually does become, the instant ‘go-to’ mantra. And questions certainly do need to be answered about this fire’s extraordinary spread. It became clear immediately that external cladding was not only flammable but had been attached to the building so as to create a void behind it. It was also quickly confirmed that recent renovation did not include retrofitting sprinklers and that there was no effective alarm.

But we need to know much more than this. We also need to understand what was, or what should have been known or suspected, about the dangerousness of materials, design and practices. As Niall Howson of the Association of Fire Protection told the BBC yesterday, fires involving cladding on high rise buildings are not uncommon worldwide. In light of this, why were regulations not up to date, why did the combination of regulation, renovation, oversight and inspection fail? It will not be enough to suggest that most related cases to date happen to have occurred outside the UK and so were unknown. More urgently than an inquest or public inquiry might be able to address, we need to know the implications of design or material failures for emergency procedures that direct people to stay in their apartments rather than evacuate. We also need to imaginatively project the safety implications of these failures onto many other potential scenarios.

One grave suspicion of course, is that as safe materials, proper practices, resources, training, and oversight systems do not come cheap, years of cost-cutting, ‘business friendly’ regulatory adjustment and less regular inspection have achieved a terrible conjuncture in this conflagration. For this possibility to be examined we also need to know how changes in the control and management of social housing have shifted, dispersed or blurred responsibilities for safety. National and Local Government have long ‘incentivised’ a shift of housing from local authority control. One local resident complained after the disaster of a “whole chain of organisations who have been subcontracted in an attempt at plausible deniability”. Fundamentally, an inquiry or inquest must get to grips with deep political currents. Ultimately, it must force governments to reverse and undo political, financial and economic values and practices that drive safety negligence. Building bonfires of regulations might suit the business classes but their cost, as we see before us, can be devastating.

Any inquest or inquiry should also include the humanitarian response. Serious concerns have already been voiced about the local authority’s performance. To be clear, there will be important aspects of humanitarian work that will not be visible from the outside. Rehousing people and supporting the bereaved will not be going on in full public view. But these concerns are serious and should be addressed. Importantly, questions here should reflect not just on performance during the incident but also on pre-incident preparation and resourcing. Poor or underfunded organisations do not magically improve when crisis strikes. The understandable temptation in austere times is to see preparation for disasters that may never happen as an unaffordable luxury. If this was the case in a borough as wealthy as Kensington and Chelsea it will raise a whole set of wider questions.

Acute disasters are followed by long and painful processes of ‘sense-making’, both individual and social. At the social level it comprises criminal investigations, inquests, inquiries, political and public debate. Whether what will eventually come to pass as ‘justice’ meets public satisfaction remains to be seen. That is a different issue to what I am discussing here, that is, establishing truth. But even for truth, the questions that need to be addressed strike to the heart of Britain today. Recent research estimating a 30,000 annual austerity ‘excess death’ rate, speaks of a society where some lives matter far more than others and where some matter not at all. The very strong suspicion is gathering that the Grenfell Fire will come to be seen in precisely this light.