Grenfell Tower; systemic failure

The day after the Grenfell Tower Fire, once I had analysed and made sense as best as I could, the unimaginable devastation that I had witnessed on the previous day when I attended the incident, I realised that the consequences for such an awful loss of life and destruction of property were going to be far reaching.

At the time, the media were full of praise for the herculean efforts of my colleagues in LFB and they thankless task they faced trying to save lives in a building that was completely alight and with every system designed to prevent fire not only failing but actually making the spread of fire and smoke worse in its unpredictable nature.

I have never really thought about where my natural cynicism comes from, maybe an adult life lived in the past few decades working for a public body where soundbites and promises often end up with those on the front line working harder and less efficiently, while the ‘good ideas club’ slap themselves on the back and walk off into the sunset. Maybe it’s living in a society where at a pretty young age I recognised media headlines were often style over substance and a quirky banner headline, a handful of quotes taken out of context was worth so much more than objective impartial analysis.

So, it was in the numbing days after the fire, I realised and made it known that somewhere down the line the LFB would shoulder a lot of the blame for the loss of life on the night. Within that first week after an appalling misreading of the public mood, those in Government came belatedly spluttering out of the starting blocks promising a public inquiry and that lessons would be learned. Those in my line of work, who had been around for many years had seen and heard all of this before knowing full well the promised lessons learned from previous disasters were, by and large, now being used as door stops or gathering dust on a shelf.

Throughout that summer, my mood darkened as the Grenfell Survivors were not given the scope of the public inquiry that they felt they deserved. More and more departments, organisations and companies were potentially implicated by cost saving, oversight and blunder, many of which if rumour is to be believed cut a path directly back to people who may sit in lofty positions with the establishment.

Finally when the scope of the inquiry was publicised and we found out that unfathomably it was going to look at the ‘Events of the night’ first, before even beginning to look back at everything from deregulation to disentangle business from red tape to the fact that Grenfell Tower was clad in flammable material and fire stopping was as good as non-existent. At that point, I knew that today…. the day I read the handful of words or sentences taken from a thousand pages of the phase one report and tuned into damning headlines… was coming.

Unsurprisingly, the day after the embargoed report is made public, the media have got their hands on it and laid a smooth and well-lit path blaming the Firefighters for the loss of life that night with barely a word about how the building had catastrophically failed within minutes of their arrival.

I have said before, so won’t go into great details again how the learned experts who analysed the events of the night second by second with great hindsight in the cold light of day have come to conclusions after hours of detailed analysis that Firefighters on the ground only had seconds to do at an incident that was completely unprecedented in terms of the cladding fire in UK experience but disastrously and uniquely coupled with total failure of the compartmentation and fire stopping. This fact alone makes the Grenfell Tower fire an event not seen anywhere previously.

The report details that the ‘Stay put’ advice should have been abandoned between 01:30 and 01:50. It is a matter of fact and record that no Senior Commanders from LFB were in attendance at the incident until after this time. A couple of middle ranking Station Managers had arrived and were immediately swamped with trying to make sense of the multiple fire survival calls they found themselves in the midst of.

So, the personnel, through an absolute mist of shock and horror trying to make sense of information that was changing, for the worse, second by second, were the handful of appliance commanders on the scene. These brave individuals who the organisation expects to command incidents where four Fire engines and around 20 Firefighters are in attendance, were expected to have the clarity in the ‘fog of war’ of a small Military platoon facing a sudden unexpected onslaught from several regiments of the enemy, to recognise that Stay Put had failed and should be reversed.

In the midst of that constantly changing environment where every second of change required a minute of thought it was so desperate, I implore anyone to explain to me how you come to that decision. Again, as discussed previously. Even if by some miracle of divine intervention that decision was made…. at 01:30 to give them the best chance. How was that to be communication to the hundreds of residents still in the tower at that time?

There was (for very good reason that I will not go into here) no public fire alarm. In the noise and confusion would people, especially those who were still blissfully unaware at that time have heard or taken notice of loud hailers. Evidence from some survivors and tragic testimony from some of those who were trapped clearly demonstrates some people did try to escape and facing choking blinding smoke & fumes either went back, went further up into the building to escape the poisoning atmosphere or got no further than opening their front doors.

It is true that a number of people took that brave decision and were able to escape, some barely conscious as they got to safety, others collapsed and resuced by Firefighters on the stairs. But if the order to evacuate had been communicated and heard, how were the LFB meant to encourage those people to make an orderly escape?

Witness testimony from many Firefighters for those who have been bothered to read it, is littered with reports of crews who did reach people in flats on upper floors where they often refused to open doors or found escape untenable and remained in their flats, or most tragically Firefighters, physically exhausted from the climb to those higher floors in heat, smoke & debris quickly realised that to remove people was to condemn them to a certain death within minutes of leaving, at that time, a relatively safe environment, not being able to comprehend the spread of fire that was to follow.

I am afraid, for all of the great minds and detailed analysis and investigation into the night of the fire, this seems to have been overlooked. I admit to having had no sight of the report as yet, but even if the facts I mention above have been included, they have been overlooked in what appears to be conclusions built solely on technical analysis without any consideration of human behaviour, emotions, lack of experience of this type of failure anywhere previously and an understanding of the utter horror those responding, trapped or witnessing had to endure.

In summary, I can only conclude with as much objectivity as I can muster having been involved in the incident, that although mistakes were made by LFB, these were not reasonably predictable in terms of the rapid deterioration of events on the night and as such the conclusions of the report have, in my opinion almost been pre-determined to scapegoat the London Fire Brigade and its personnel to what end?

Sytsemic Failure. Those are the headlines today in relation to the LFB. I’d argue that systemic failure has appeared everywhere in the sorry tale of the Grenfell Tower Fire. From deregulation of Fire Safety laws in the early 2000’s, from the apparent cost cutting and poor oversight of the refurbishment of the Tower, to the way in which the inquiry was set up about face and the conclusions drawn at the end of phase one.

46 thoughts on “Grenfell Tower; systemic failure

  1. Well thought out and written Steve. I can’t imagine the levels of stress this is going to revisit on all of those involved that night. Stay well, stay safe

    • As an incident commander in large Canadian city what arriving fire crews incountered that fateful evening was completely out of control and well beyond stopping fire load as well rescuing trapped citizens

      When people /contractors are allowed to build these fire traps with approval from building departments fire prevention divisions as well politicians none of them paying attention to the details that they knew damn well it was not if it would be a disaster but when. The report speaks for itself someone in much higher authority blew this one not first arriving fire crews

  2. A well described assessment of the events and problems face by the firefights on the night and shows the total lack of the understanding of the unprecedented situation firefighters face with their rescue attempts.

  3. Well said, my son was one of the first in, utter chaos. I’m so angry that he and his fellow firefighters have any blame thrown at them

  4. Well versed Steve we in the know are feeling your thoughts and frustrations. Clearly the LFB are now going to receive the criticism we knew was coming from those that know so little.

  5. I have seen many scenes as a police scenes of crime officer but can’t imagine the enormity of this disaster. I was diagnosed with PRSD and cant imagine how the firefighters who attended the scene are coping . I am so angry and disgusted that the blame has bee laid on the LFB

  6. Steve, my sincere congratulations for an incisive assessment of the cause and the events of the evening.
    Unless someone has been in a fire, been in charge of a fire, in both the initial stages and after it has developed, they have no idea of the amount of information you receive and the decisions that have to be made within seconds. There is no looking up of guidance, how it should be done or operational notes. Sure there is a process of ‘what ifs’, but they are based on previous experience and the results of study. But everything is based on what is realistically going to happen.
    The events of that fateful night would have been regarded as fantasy, if presented as a desk top exercise, because nobody within the Fire Service, or even within a Local Authority Building Control come to that, would have believed there could have been such failings in what, when built, was an intrinsically very safe building.
    Unfortunately the leaked report is a slur on the LFB, the British fire service and everyone who has been a firefighter.
    I can see that it can only fuel the flames of racism levied against the LFB following the accusations of both Lady Lawrence recently, and her solicitor last year.
    I have been retired for some time now but even I feel like I’ve been hung at to dry.
    Once again Steven, a very good peice of work which should be published and continually referred to when discussing the outcomes of that dread fully night.

  7. Long before you look at the Fire Service, look at successive Governments. Look at the Civil Service, look at the local Government and the suppliers of the flammable cladding. They are the culpable parties for the loss of life.

  8. Well said Steve,no Firefihters,or contro staff have faced anything like this in UK fire services,as you rightly pointed out the inquiry is back to front,should have started with the history of the tower,poor maintenance, lack of housing association management,and deregulation of fire safety to local council and property owners.

  9. Well written piece Steve. As ever an inquiry that is quick to rush to judgement without fully understanding the realities of what happened – hindsight is a great thing and not the first time it has been used to blame the responders rather than the actual causes and failures. Begs the question – is this the kicking that leads to privatisation? People will see the headlines and make the conclusion that private is better than public as the LFB will be unable to respond to the negativity without emotional attachment.

  10. A very insightful report on an appalling catalogue of errors perpetrated by neglect and incompetence shown by decisions of the ruling bodies who oversaw the actual renovation of this building and the shoddy materials and workmanship which resulted in this devastation. Hang your heads in shame and do not allow our brave fire services to be the scapegoats of your crimes.

  11. As usual Dudes a well worded and heartfelt piece. I was fortunate to have retired 2 months before this tragedy and as such spared the horrors you and all the firefighters had to endure. We knew that despite all the heroic efforts of all who attended we (LFB) we always in for the proverbial kick in that was going to come our way. I say our way because anyone who has ever served in the LFB is likely feeling the pain of betrayal when you hear headlines like Systematic failure etc etc. The people that matter colleagues and ex colleagues from the LFB and FRS around the country know the impossible task that you all faced and all the Captain Hindsight’s who now say you should have done this or should have done that don’t have a clue.
    To all my friends and former colleagues hold your head up high because we are very proud of what you all did on that night and the days that followed and proud to have served with you all. Without the actions of the LFB many more would have died don’t ever forget that. Thank you all Daryll Stroud

  12. Well written again Steve, It is so easy to blame a soft touch(i.e the LFB) When the real blame should lay with the council and building contractors who allowed such highly flammable material to be used in the refurbishment.
    And as for the comments by the so called Lady she should be stripped of her title. Enough said for fear of being called a racist what with being a retired London Firefighter myself.

  13. I’m not a firefighter, merely the father of one who went into that hell three times. I watched that building burn knowing that my son was inside, knowing that he wouldn’t give up trying to save people until he had absolutely nothing left to give,. Knowing that he would then find something, from somewhere, so he could carry on. He did and suffered as a result. Not only physically but mentally. He thought he was going to die but went back in again and again. He this inquiry is an abomination! My son is Ricky Nuttall and I am the proudest father in the world.

  14. All too true Steve, I work in the construction industry and know all too well about so called ‘value engineering’ , poor regulation Sub standard certification. The LFB have nothing to reproach themselves for. You are scapegoats and it’s an utter disgrace.

  15. Your summary is spot on, there was know way the LFB were not going to be blamed for this terrible incident as that way it takes the pressure off the politicians who should be held accountable. Let’s get this right they are all responsible whichever party you support. Shameful behaviour

  16. I have been angry all day by the reports,accusations and so called experts. Like many before attend an incident,make snap decisions and most of the time correct. Total agree with the comments love us when it goes well hate us whe it goes wrong and it’s not our fault. 30 years most of the time in EFRCS.

  17. Thoughtful and important words Steve. No surprise that the blame team have rounded on the LFB and will deflect as much attention from themselves as possible. I know that the incident commanders that night faced an unimaginable task, but also know they would have been using every ounce of experience, knowledge and sheer bloody will to save people. No amount of training could have possibly prepared for that night.

  18. 👏👏👏 110% on the nail as always Steve. So, the Lfb should have evacuated a single staircase, smoke filled tower block, with no means of communicating that escape to residents, and that we can no longer assume any longer that any system put in place to safeguard residents will do as its supposed to. Well that report was a total waste of time and money, and I’m feeling is an insult to all those who perished. Frankly I’m glad I’m counting the last few pay packets until I retire, this whitewash has killed the last bit of enthusiasm I have for the job. 😞

  19. Do NOT let them corrupt you. I am not a Firefighter; I had never heard of Grenfell Towers before this terrible night..

    I challenge any one of your critics to enter a burning building or attend a serious Road Traffic Accident and to walk away having been of value. You were, and you ALWAYS are.

    From the bottom of my heart, I am thankful that you are in the world I inhabit.

  20. A great summing up of the whole situation Steve. To my practised mind from over 25 years of exposure to both fire incidents themselves and the design and provision of fire control procedures whilst the provision of legal controls were in place I consider that the leaks of items from the report are crass and unfounded.. Why does this always happen after loss of life in emergency situations, Blame is always levelled at those who put their life on the line to attempt to save others. Point the finger in the right direction, how about the Government who removed the legal control by experts in the field of fire safety by removing that regulation ? which council departments allowed cowboy builders to remove fire safety provision within the building and to provide sub-standard materials to clad the outside? I could go on and on apportioning blame, but would never point the finger at LFB who tried their best to rescue as many people as possible from a horrendous situation caused by others. …….

  21. Thank goodness there is a perspective from the cold face to offset the scapegoating & those ‘experts’ with the benefit of hindsight. Thx Steve.

  22. This is a well written piece, accurate and heartbreaking. I truly believe that it has been pre-determined, Milton Friedman wrote the rule book for this strategy. I’d suggest that if you want to know why, look at a hedge fund company called Elliott Management, then, look at AT&T, Vodafone and Firstnet. Link these firms together and a very lucrative solution to the situation awareness ‪& comms problems on that night will materialise. LFB and UK firefighters will be used as the excuse for it’s requirement. Even more worrying is the concern over national security that Firstnet (or whatever it will be known as in the UK) raises. Basically, Firstnet is the US government, it’s HQ is in Virginia. Our people from the home office have been meeting with them prior to Grenfell & after. A lucrative telecoms expo was held in London and Firstnet members we’re in the UK, this conference was held the night of Grenfell. I’ve not read the inquiry reports either but I bet you the majority of findings point to communication problems and it will suggest technical solutions.

  23. Good article Steve.
    For me, government departments changing fire safety legislation, for their own ends, is the primary cause.
    Taking an inherently safe building, constructed from concrete with two hour fire compartments and completely negating the compartmentation and fire seperation, is the result.
    The inquest was a joke, the crews went above and beyond, and I am in awe of their selfless attempt to save the occupants.
    The brigade are being used as scapegoats and it disgusts me.
    I have no specific knowledge of this particular incident, but would like to know, if “approved inspectors” were used on the “renovation” work?

  24. My husband was an OIC that night. Hanging the brigade out to dry, shielding the truth as ever.

    For the people who are making racist slurs against the brigade it should be said that the fire service is multicultural.

    Much respect to every single man/woman on the scene that tragic night.

  25. I was a firefighter for thirty years and cannot imagine the scene met by the first and later crews in attendance. The bravery of the crews should be highlighted and not condemned through failure of other factors such as compartmentation beyond their control.
    The field service have always been silent about what they see, do and achieve under mostly difficult circumstances that the average person would not even contemplate.
    We, it seems are going to be the scapegoat and easy. Targets for those that should be accepting responsibility
    The firefighters of LFB should hold their heads high.

  26. It’s beyond comprehension how the powers that be can lay the blame at the feet of the Firefighters and their Commanders. The buck should stop at the “top” i.e. the Government for lack of funding and the Local Authorities cutting corners. How dare anyone put any blame on the LFB – utterly disgraceful.

  27. Not a lot to say as previous posters ahve said it all. . People who critise, who shout and complain, are you listening Doreen Lawrence would never strap on a BA set and go into a situation which they may never come out from. Stay safe guys

  28. Let them who condemn us go into a heat filled smoke filled chamber with no plan of the lay out try it I will love to see there reaction if anyone is to blame it the councils cuts and the allowance of sub standard materials that killed them people we fight fires we scrape people up of off the floor or go into underground stations and lose our lives doing so with out any hesitation on a daily basis join up and try it you won’t last a week so lay of the fire Brigade you never know when you will be preying that these Hero’s will go in your house and rescue your family a retired firefighter who is in a wheelchair because of injuries I got doing my job x

  29. Dear LFB,

    I cannot prevent an inquiry panel from blaming the very people – the only people – who were there, at such phenomenal personal risk, trying to save lives but (it appears) hindered by the “corporate policies” of the day. Neither can I prevent the media exploiting one unfortunate turn of phrase by the Head of the Service, intended (I believe) to robustly defend the position that those policies had been complied with. Such a statement is not an offence, even if it might have been better phrased. That said, as an individual, I can see through the initial findings and I can disregard the two-faced media hype. So I do. It will be enlightening to see what the rest of the inquiry comes up with but nobody should pre-judge that.

    LFB, I wish to publicly state my absolute and utter trust in every single one of you. Please be there, should I ever need you. Members of the Inquiry panel: I pray to God that you are nowhere near.

  30. Good points well made, to not look at cause and construction before looking for blame shows poor judgement

    Keep your heads up all members of LFB you are hero’s who deserve credit

  31. The establishment are playing the Hillsborough play book, blame anyone that fits their narrative away from the culpable
    but this time people aren’t buying it

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