grenfell tower inquiry- fbu’s supplemental opening

Grenfell Tower Inquiry- FBU’s Supplemental Opening Submissions for Module 5 of

Phase 2 confined solely to the issues arising from the subject matter of Dr Stoianov’s report

IN THE GRENFELL TOWER INQUIRY

Chaired by Sir MARTIN MOORE-BICK

Sitting with fellow Panel members Thouria Istephan and Ali Akbor OBE

Advised and assisted by Assessors, currently: Joe Montgomery CB, Professor David Nethercot OBE, and John Mothersole

FBU’s Supplemental Written Opening Submissions for Module 5 of Phase 2 confined solely to the issues arising from the subject

matter of Dr Stoianov’s report

The FBU and the firefighters, Control staff and fire safety officers we represent

remain humbled by the suffering of the deceased and the bereaved, survivors

and relatives of the deceased (BSRs) as a result of the Grenfell Tower disaster;

and committed to a full and open inquiry.

The Key findings of Dr Stoianov

2.1 ¯Water supply There was enough water available, if managed properly by the

London Fire Brigade (LFB) and Thames Water Utilities Limited (TWUL), to

supply the aerials which could have applied water to the top of the tower. It is

not known what difference this would have made to the outcome.

2.1.1. There were 3 swimming pools in close proximity to Grenfell Tower with

enough water to supply an aerial for over 5 hours.

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Grenfell Tower Inquiry- FBU’s Supplemental Opening Submissions for Module 5 of Phase 2 confined solely to the issues arising from the subject matter of Dr Stoianov’s report

2.1.2. A wash-out hydrant was wrong labelled ’fire hydrant’ and used as such

on the night. It was not designed to and did not supply water at the

required flow rate.

2.1.3. There was no bulk media adviser before 6.30am, i.e. for most of the

night, after Group Manager (GM) Welch, who had been assigned the

role, was diverted to other duties (5-122, lines 10-14).

2.2. Knowledqe

2.2.1. Insufficient knowledge about the operational characteristics (e.g. rated

flow rate and nozzle inlet pressure) and how to fully utilise an aerial

appliance (e.g. the turntable ladder) as a water tower is exemplified in the

witness statements made by both senior LFB officers and also

experienced firefighters who are trained operators of aerial appliances

and pumps {ISTRP00000006/57:19-22}.

2.2.2. This led to poor communications between LFB and TWUL: the LFB did

not specify, and TWUL did not proactively find out, what was needed.

2.3.Criticism Dr Stoianov makes no personal criticism of LFB firefighters and

officers: "Throughout this Report, where relevant to my instructions,

investigation and conclusions, I have commented on the actions and

statements of a number individuals, including LFB firefighters and officers,

Network Service Technicians and other TWUL employees. None of this

analysis is intended, nor should it be taken, as personal criticism of the

individuals concerned. I have no doubt that they acted to the best of their

ability in the extremely difficult circumstances on 14 June 2017"

{ISTRP00000010/4}.

As to criticism

3.1.The firefighters and officers referred to in Dr Stoianov’s report should not be

criticized because:

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3.1.1. they were not trained sufficiently to enable them to use the facilities

and make the adjustments necessary to provide a sufficient flow rate to

the pumps adequately to supply the aerials and ground monitors. This is

evident from the lack of knowledge of the firefighters referred to in Dr

Stoianov’s report. The firefighters should not be criticized for failing to

augment water supplies when they were not trained how to do so. This

lack of training may provide at least a partial explanation of what Mr

McGuirk struggles to understand about the lack of any command

decision to address water supplies from the arrival of GM Welch until

05:50 {SMC00000046/62:161-167}.

3.1.2. Neither the mobile data terminal (MDT) nor the operational risk

database (ORD) made recommendations about the water supply setup

for an aerial appliance for Grenfell Tower in case an aerial appliance had

to be deployed. Furthermore, the information in the MDT/ORD about the

location and operational status of fire hydrants in proximity to Grenfell

Tower, was incomplete and inaccurate {ISTRP00000006/46:25-29}. Dr

Stoianov reports that the water supply problems were significantly

hindered by the inaccurate and incomplete information about the location

and status of fire hydrants, which LFB had for the area around Grenfell

Tower {ISTRP00000006/5:84}. These failings were the result of

institutional, not individual, failure {Vol.4 §27.20}.

3.1.3. The swimming pools were not referenced in the ORD/MDT and there is

no evidence firefighters were aware of their existence.

3.1.4. There was a dearth of national research and guidance for local FRSs

to apply to the development of procedures and training to maximise the

provision of water for fire-fighting. Dr Stoianov advises that:

3.1.4.1. as with flow rate, legislation provides no specific numerical

requirement for the quantity of water, beyond the requirement in the

Fire and Rescue Services Act to secure an ’adequate supply’ of

water. {ISTRP00000010/9}, and

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3.1.4.2. the National Guidance Document on the Provision of Water for

Fire Fighting (LGA & Water UK, 2007) is deficient in detail and

clarity; and it lacks the consideration of critical issues that are

required for the provision of adequate water for firefighting and the

use of modern firefighting equipment {ISTRP00000010/10}.

3.1.5. Water supply problems encountered in high-rise firefighting were

identified by Dr Paul Grimwood in the Harrow Court Inquest giving rise to

coronial recommendations including NH44 "... "That HFRS immediately

commission an in-depth detailed examination into the suitability of using

the Delta H 500 65f for compartment firefighting in high rise buildings",

NH45 "...That HFRS should immediately revise its High Rise Incidents

procedures taking into account the final outcomes from this particular

investigation, the equipment required to be taken up to the bridgehead

and particular attention should be made to the guidance given with

regard to water pressures, flow rates and tactical firefighting", and NH73:

"... (e) Water supplies and equipment. Evidence was also heard

concerning the efficacy of the equipment used and the water pressures

available at a firefighting branch in such circumstances. Attention was

given to Port 4/205 used by the Office of the Deputy Prime Minister in

December 2004...".1 The failure properly to consider Mr Thomas’

recommendations is another example of institutional failure at a national

level.

3.1.6. The individuals involved in the emergency response have not been

afforded the opportunity to respond to any criticisms which may yet be

made by Mr McGuirk or the Panel. The FBU reserves the right to

approach named individuals for further witness evidence in the event that

Mr McGuirk or the Panel make any criticisms. It is not proportionate to

1 FBU Health and Safety Investigation Report - 85 Harrow Court, Silam Road, Stevenage, Hertfordshire

{CWJ00000069}. These recommendation were also sent to DCLG under cover of a letter dated 8 March 2007, and all FRSs and all Social housing providers were again encouraged to read these recommendations in Recommendation 5 of HM Coroner Wiseman’s Recommendations following the Shirley Towers fire.

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Grent ll Tower Inquiry- FBU’s Supplemental Opening Submissions for Module 5 of Phase 2 confined solely to the issues arising from the subject matter of Dr Stoianov’s report

conduct that exercise on the basis of Dr Stoianov’s report in light of his

decision not to criticize anyone personally (see above).

As to the failure to augment the water supply

4.1 .The failure to augment water supplies has to be viewed in the context that

the of the rapidly developing fire which had already caused widespread

breach of compartmentation externally by 01:26, and internally also by 01:40

with heavy smoke logging in several lobbies, fire and smoke entering flats on

multiple floors and light smoke affecting the single staircase {Vol.4 §25.10-

13} and ultimately leading to a total failure of compartmentation {Vol.4

§24.39}.

4.2.The tower should not have been occupied after the rainscreen cladding

system was installed in the main refurbishment and the LFB should not have

been called upon to respond to a fire of this magnitude.

4.3. Firefighters in the first hour of the emergency response, including WM

Dowden and SM Walton, cannot reasonably be expected to have augmented

water supplies given:

4.3.1. the adequacy of water flow to carry out the firefighting procedure for a

compartmentation fire, which was successfully extinguished in Flat 16;

4.3.2. the rainscreen cladding system was designed to repel water and the

fire could not be reached until after a sufficient number of panels had

fallen away;

4.3.3. the delayed arrival of aerials left them unaware of any significant

problem with water supplies until the first aerial became operational and

experienced water supply problems. This was after 02:05am;

4.3.4. Mr McGuirk rightly excludes WM Dowden and SM Walton from his

criticisms of later incident commanders for failing to address the water

supply problem {SMC00000046/62:161-167};

4.3.5. WM Dowden decided to make pumps 8 at 01:19, and messaged

control, to that effect whereupon a bulk media adviser (BMA), GM Welch,

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was mobilised. Water was a medium for his consideration. GM Welch

attended in this role, booking status 3 at 01:57 {Vol.2 §13.58}. However,

he dispensed with his BMA responsibility in favour of assuming

command of the incident at around 02:00, and when Deputy Assistant

Commissioner (DAC) O’Loughlin took command shortly after this, he

assigned GM Welch to be fire sector commander inside the tower without

re-assigning the role of BMA {SMC00000046/58}. GM Welch is not a

member of the FBU and is separately represented in the GTI by his trade

union, the Fire Officers Association (FOA). In the event, as Dr Stoianov

has found, there was no bulk media adviser before 6.30am, i.e. for most

of the night (see above);

4.3.6. Following the high-rise firefighting procedure PN 633 and the

mobilisation policy of the LFB, there was not expected to be a BMA at the

scene until shortly before 02:00am.

4.4. Likewise, firefighters in the second hour of the emergency response should

not be criticized for not augmenting water supplies, the second aerial

appliance, Soho’s ALP (A245) arrived at the incident at about 01.52 and was

also (albeit sequentially) sited on the east side of the tower, on the grass and

behind the trees, about 7 metres from the tower. It took about seven minutes

to set up. Far from criticising them for failing to augment the water supply, Mr

McGuirk advises the crew (CM Christopher Frost and FF Jason King) should

be commended for their initiative in manoeuvring the appliance to the

position it then occupied for much of the night (until Surrey’s ALP arrived)

{SMC00000046/63}. They lashed a high-pressure hose reel onto the cage of

the ALP and, from about 2.30am {Vol.2 §14.120} applied water to the east

face for around 5 hours (from about 2.30am), thereby limiting the spread of

fire around the areas to which water was applied.

4.5. Not trained: Pending further evidence on their training, it is likely that only

BMAs were trained on how to augment water supplies. Assuming so, the

firefighters, including incident commanders and command support officers

who were not also ’BMA qualified’ were not so trained and should not be

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criticized for failing to appreciate something could have been done to improve

the supply of water.

4.6.1n light of the rapidly developing fire, albeit pending Mr McGuirk’s further

opinion in light of Dr Stoianov’s report, the FBU questions whether water

supplies could realistically have been augmented in time to make the

operational response more effective in the early stages, up until about 02:05.

Thereafter, better water supplies may have slowed the fire development and

made conditions better thereby assisting both search and rescue

deployments and those trying to self-evacuate. This is a matter for expert

evidence which is awaited.

5. As to Aerials:

5.1 .The first aerial appliance was requested at 01:13 {Vol.2 §10.59} after which

Paddington’s turntable ladder A213 arrived at 01.32 {Vol.2 §11.8}. It took a

further 10-15 minutes to become operational {Vol.2 §11.9} i.e. by about

01:47. It then applied water to the east face of the tower until sometime

between sometime between around 02.10 and 02.25 {Vol.2 §14.118}. It was

pictured by Dr Lane applying water to the east fagade at 02:05, reaching

about floor 10 before it had to be moved due to falling debris {Vo12. §12.22}.

5.2.The FBU contends that, even without augmenting the water supply, it may

have made a difference to either incident command decision making, or the

spread of fire, or both, if an aerial appliance had been mobilised at about

00:55 as part of the pre-determined attendance (PDA), had arrived by about

01:13 and had become operational by about 01:25 (about 22 minutes earlier

than A213 became operational). Please see the FBU’s written closing

submissions for Phase 1 at §§52-53, and our Phase 1 oral closing

submissions on 12 December 2018 {Ph.l, T88:46/1:5}.

&&Additionally if an aerial had been included in the PDA, then PN 633 would

have provided for the early arrival of an aerial whereupon training for high-

rise firefighting and section 7(2)(d) inspections would have covered the use

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Grent ll Tower Inquiry- FBU’s Supplemental Opening Submissions for Module 5 of Phase 2 confined solely to the issues arising from the subject matter of Dr Stoianov’s report

of an aerial, probably leading to increased knowledge and experience,

including about the water supply needed for such appliances and how to

augment available supplies.

5.4. In this scenario we consider the likely different outcome if an aerial had been

mobilised with the PDA without augmenting the water supply. In this scenario

the ineffectiveness of the aerial to fight the external fire would probably have

become clear to the incident commander before the arrival of Paddington’s

Fire Rescue Unit A216 at 01:35. This would have helped WM Dowden to

formulate a different plan other than trying to fight the external fire by a pincer

attack from the roof and with the aerial. It would have influenced the

discussion between WM Dowden and SM Loft at about 01:40 {Vol.2 §11.6}:

whereas they both believed this firefighting plan to be realistic, they would

probably have abandoned external firefighting if they had already seen the

ineffectiveness of the aerial in fighting the external fire. That would have

forced them to consider other possibilities, including the revocation of stay

put, which the Chairman has found should have been considered at this very

time (between 01:30 and 01:40). This scenario has yet to be considered by

Mr McGuirk, the Chairman or the Panel.

Martin Seaward [email protected] 7 September 2021

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grenfell tower inquiry- fbu’s supplemental opening

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