Grenfell Tower Inquiry: First Report says “many more lives” could have been saved.

The report of the first phase of the Grenfell Tower fire exposes how the fire started, spread and became a disaster. Before some of the key conclusions which will affect the broader investigation of the inquiry’s second phase, here you have a reminder of the events as they unfolded.

                                                                                                                          There was swift action by the resident of the flat where it began.

The first 999 call came from Behailu Kebede at 00:54 BST, who lived in Flat 16. His smoke alarm woke him up and he saw what was in all likelihood an electrical fire at the rear of his fridge freezer. He called for help, informed neighbours and waited for the London Fire Brigade to get there.

Sir Martin Moore-Bick’s statement found Mr Kebede innocent. He turned off his power and shut the flat entrance to keep others safe.

In typical situations that would have been sufficient because Grenfell’s original solid concrete construction determined each flat was “compartmented” – suggesting a minimal risk of a fire spreading.

Sir Martin Moore-Bick, inquiry chair, said the resident who raised the alarm was blameless

But his attempts were in vain because of how the building had been redecorated on the body.

The first firefighters into the flat realised something was wrong

Crew manager Charles Batterbee and firefighter Daniel Brown got into Flat 16 at 01:14 BST. They blasted the fire with a jet of water and then saw the fire had now reached from the kitchen to the outside.

This is the first evidence that Grenfell’s refurbishment was contributing to the disaster. Hot material deformed the uPVC window and that formed a hole through which hot fumes emerged.

They blasted water at the cladding flames to no avail. The polyethylene material in the rain-proof cladding boards was melting and burning.

“It then became apparent that the fire was moving up the building,” said Mr Brown.

“I remember the intensity of the flame – what I can only describe as huge balls of flame falling down along with debris. It didn’t stop, we kept hitting it but again, it was having no bearing on the fire.”

The importance of calls from some residents was missed

Sir Martin is in no doubt that Grenfell Tower’s refurbished outside walls were not compliant with building regulations “because they did not adequately resist the spread of fire over them. On the contrary, they promoted it.”

Once the fire escaped from Flat 16, the flammable nature of the cladding panels allowed it to spread to the top storey in less than half an hour – but also around the sides.

The fire reached the “crown” of the building at 01:27 BST and the top cladding spread flames horizontally and eventually back down.

And that’s why the 999 call moments later from Mariem Elghwahry, who lived on Floor 22, is important. She was the first to notify fire entering her flat.

Within half an hour of firefighters’ arrival, there were indications that Grenfell’s compartmentation was failing.

Control room workers couldn’t cope with the calls

When a fire service receives multiple emergency calls from the same incident, control room operators tend to class the further ones as “Fire Survival Guidance” calls (FSG) in which they provide the individual information about the fire and what they require to do to stay safe.

The statement makes clear that the control room supervisors seemed not to have undergone any particular training to handle the number of calls concerning Grenfell.

Operations manager Alexandra Norman told the hearing that staff would usually stay on the phone to FSG callers until they were safe – but they were overwhelmed.

Sir Martin said: “When the flow of FSG calls became a flood around 01:30 to 01:40 OM Norman should have stood back and determined how to manage the collation and transmission of FSG information to [teams on the ground] in a way that secured that clear lines of communication were set.

“OM Norman failed to ensure that [call handlers] obtained from callers all the information required.”

And teams on the ground struggled too

Watch manager Michael Dowden – among the first at the scene – had received no training on how the materials used to refurbish Grenfell Tower would behave in a fire.

Sir Martin said Mr Dowden, who broke down in tears at the inquiry, could not be blamed for not knowing how to respond to what he was witnessing.

Mr Dowden lacked critical information from the control room – that meant that he was doubly blinded to what was unfolding.

In short, said the chairman, a relatively junior officer “had little or no support from more senior officers” and was let down by institutional failings.

He went on: “The behaviour of the fire was outside his experience and nothing he had done seemed to be having any effect. He was at a loss to understand what was happening or to know how to respond.”

Nobody had an overall full understanding of how to prioritise rescues

This is shown by the death of 12-year-old of Jessica Urbano Ramirez. No information from her 999 call at 01:29 BST made it to the crews. A team only went to her home on floor 20 after receiving news from Jessica’s sister. By this time, she had escaped three stories higher with 10 others.

In the meantime, control room officer (CRO) Sarah Russell stayed on the phone to Jessica for 55 minutes. It was obvious she was in terrible danger. Jessica stopped answering but CRO Russell could still hear the sound of breathing for some time. She only ended the call when the line went quiet.

Jessica’s call for help was the first FSG call that CRO Russell had taken. In her witness statement, she told the inquiry: “Reflecting on that call, I felt completely helpless.” Sir Martin praised her courage and calm professionalism amid the tragic circumstances of attempting to help a 12-year-old survive.

The “stay put” strategy should have been abandoned sooner

 Fewer people would have died in the disaster if London Fire Brigade had not suffered “serious shortcomings” and “systemic” failures in its response to the fire, the official report into the tragedy has concluded.       

“The evidence taken as a whole strongly suggests that the “stay put” concept had become an article of faith within the LFB so powerful that to depart from it was to all intents and purposes unthinkable,” he wrote.

“The fact that the commissioner [Dany Cotton] was forced to ask the rhetorical question: ‘It’s all very well saying, get everybody out, but then how do you get them all out?’ indicates that the LFB had never itself attempted to answer that question in its preparations and training and had not equipped itself to carry out an entire evacuation of such a building.

“Quite apart from its remarkable insensitivity to the families of the deceased and to those who had escaped from their burning homes with their lives, the commissioner’s evidence that she would not change anything about the response of the LFB on the night, even with the benefit of hindsight, only helps to confirm that the LFB is an institution at risk of not learning the lessons of the Grenfell Tower fire.”