grenfell tower inquiry- fbu’s supplemental opening
TRANSCRIPT
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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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
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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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
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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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
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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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
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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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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