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HC 49-IV – the Grenfell Tower Inquiry: Phase 1 Report

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HC 49-IV – the Grenfell Tower Inquiry: Phase 1 Report GRENFELL PHASE INQUIRY: TOWER 1 REPORT GRENFELL TOWER INQUIRY: PHASE 1 REPORT REPORT of the PUBLIC INQUIRY into the FIRE at GRENFELL TOWER on 14 JUNE 2017 Chairman: The Rt Hon Sir Martin Moore-Bick October 2019 Volume 4 Volume Volume 4 HC 49–IV GRENFELL TOWER INQUIRY: PHASE 1 REPORT REPORT of the PUBLIC INQUIRY into the FIRE at GRENFELL TOWER on 14 JUNE 2017 Chairman: The Rt Hon Sir Martin Moore-Bick October 2019 Presented to Parliament pursuant to section 26 of the Inquiries Act 2005 Ordered by the House of Commons to be printed 30 October 2019 Volume 4 HC 49–IV This report contains images and content which some may find distressing. © Crown copyright 2019 This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-government-licence/version/3 Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned. This publication is available at www.gov.uk/official-documents Any enquiries regarding this publication should be sent to us at [email protected] ISBN 978-1-5286-1602-7 (Volume 4 of 4) 4 volumes not available separately CCS0719597372 10/19 Printed on paper containing 75% recycled fibre content minimum Printed in the UK by the APS Group on behalf of the Controller of Her Majesty’s Stationery Office Part III Conclusions 503 504 Chapter 21 The Cause and Origin of the Fire 21.1 The two principal matters to be determined are how the fire started and what caused it. In answering these questions I was assisted by expert evidence from Professor Niamh Nic Daéid (in relation to the origin, cause and initial internal spread of the fire) and Dr Duncan Glover (in relation to the electrical installations and certain appliances in Flat 16). Neither expert was involved in the investigations conducted by, or under the authority of, the MPS in the immediate aftermath of the fire. Therefore, although both experts were able to visit the tower to inspect and photograph Flat 16 and to carry out such tests as they considered necessary and appropriate, they were obliged to rely to a significant extent on the evidence gathered by others. The manner and means by which evidence was recovered from Flat 16 was, in certain respects, not ideal, but both experts considered that the available evidence was sufficient to allow them to reach their conclusions with confidence. 1 Where did the fire start? 21.2 It is quite clear, and indeed no one has suggested otherwise, that the fire started in the kitchen of Flat 16. That was the evidence of Mr Kebede, Ms Afeworki and Ms Kinfu, as well as the two fire crews who entered the flat and there is no evidence to suggest that it started anywhere else. It was the unchallenged view of Professor Nic Daéid that the fire started in the kitchen of Flat 16 and that was the equally clear conclusion of Bureau Veritas and Key Forensic Services, investigators retained by the MPS to examine the cause and origin of the fire.1 21.3 A slightly more contentious question is whether it is possible to determine exactly where in the kitchen the fire started. In this regard, there are four principal sources of evidence: (i) the evidence of the occupants of Flat 16, Mr Kebede, Ms Afeworki and Ms Kinfu and the evidence of the firefighters who first entered the kitchen, CM Charles Batterbee and FF Daniel Brown; (ii) the images captured by the thermal imaging camera used by CM Batterbee and FF Brown; (iii) the burn patterns on the kitchen floor and skirting board, the large fridge-freezer and other appliances; and (iv) the evidence of Dr Glover based on his examination of the relevant electrical installations and materials recovered from Flat 16. The evidence of the occupants of Flat 16 and the firefighters 21.4 The first source is that of the witnesses, Mr Kebede, Ms Afeworki, Ms Kinfu, CM Batterbee and FF Brown. In his call to the fire brigade and when urging Ms Kinfu to leave the flat, Mr Kebede stated unambiguously that the fridge was on fire. (He later made it clear that he was referring to the large fridge-freezer at the south-east end of the kitchen.) This evidence is consistent with WM Michael Dowden’s evidence about the information he had received from Mr Kebede very soon after arriving at the tower, namely, that the fire was in the kitchen and involved “the fridge”. 1 Bureau Veritas report (dated 7 November 2017) [MET00007996] paragraph 15.1 p. 37. 505 The Grenfell Tower Inquiry: Phase 1 Report 21.5 CM Batterbee, who had entered the kitchen soon after 01.14, recalled that the fire was in the area of the large fridge-freezer2 and, having put the fire out, he remembered telling FF Brown that: “I could see what I thought was the fridge and cupboards alight”,3 that is to say, the large fridge-freezer. It was this fridge-freezer that FF Brown inspected, noting heavy damage around the top 25%.4 The thermal imaging camera footage 21.6 The second source of evidence is the thermal imaging camera footage. CM Batterbee and FF Brown captured images, timed at 01.14, which showed an elevated temperature at the south-east end of the kitchen in the area of the window and the space between the window and the large fridge-freezer.5 Footage, captured at 01.15, showed the large fridge-freezer involved in the fire.6 No other area of the kitchen was shown to be involved in the fire at that stage. Burn patterns 21.7 The third source of evidence is the burn patterns in the kitchen, particularly those on the floor where the large fridge-freezer stood, which were the subject of evidence from Professor Nic Daéid. 21.8 The following photographs show the extent of the burn marks on the large fridge-freezer itself. 21.9 Figure 21.1 is a photograph of the side of the large fridge-freezer facing the kitchen window. There are no burn marks on the laminate floor to the left of the appliance. The burn marks illustrated in figure 21.1 are, as Professor Nic Daéid noted, mirrored on the opposite side of the appliance, as illustrated in figure 21.2. 21.10 Figure 21.3 shows the appliance’s door. In Professor Nic Daéid’s view, the fire pattern on the door suggests that combustible materials to the left of the large fridge-freezer (that is to say, between the large fridge-freezer and the south-east wall) were burning during the early stages of the fire. This fire pattern could also have been influenced by ventilation effects from the nearby open window. 2 Batterbee Day 12/73/11-21. 3 [MET00012871] p. 7. 4 [MET00005251] p. 3. 5 Professor Nic Daéid supplemental report [NNDS00000001] p. 32 Fig. 19(a) and (b). 6 Professor Nic Daéid supplemental report [NNDS00000001] p. 32 Fig. 19(c). 506 Part III | Chapter 21: The Cause and Origin of the Fire Figure 21.1 507 The Grenfell Tower Inquiry: Phase 1 Report Figure 21.2 Figure 21.3 508 Part III | Chapter 21: The Cause and Origin of the Fire 21.11 The following photographs show the burn pattern on the floor below the large fridge-freezer. Figure 21.4 Figure 21.5 509 The Grenfell Tower Inquiry: Phase 1 Report 21.12 The burn pattern shows that the laminate floor beneath the large fridge-freezer was exposed to heat or flame to a greater extent than that on either side of the appliance. It is significant that the floor on either side of the place where the large fridge-freezer had been standing is undamaged. It is also of significance that the skirting board immediately behind the large fridge-freezer had been burnt away. In her oral evidence, Professor Nic Daéid carefully reviewed the burn patterns on the floor and on the large fridge-freezer, as well as the burnt- away skirting board behind the large fridge-freezer. She concluded as follows: “Looking at these burn patterns in particular, the burn pattern to the skirting board and also the damage to the sides in particular of the outside of the tall fridge freezer, where the damage runs from the bottom to the top, it would be my view that the fire was originally orientated in the base of the fridge freezer.”7 Dr Glover’s evidence 21.13 Professor Nic Daéid’s opinion is supported by the fourth principal source of evidence, namely, Dr Glover’s analysis of the electrical installations within, and certain artefacts recovered by the fire investigators from, Flat 16. 21.14 It should be noted that Dr Glover’s analysis was confined to the area of origin of the fire provisionally identified by Professor Nic Daéid and Professor Bisby in their first reports, that is to say, the south-east end of the kitchen of Flat 16. That was an appropriate basis upon which to proceed for three main reasons: first, because no one had identified any other potential area of origin; secondly, because Bureau Veritas had also identified the south-east end of the kitchen as the area of origin; and, thirdly, because neither Professor Nic Daéid nor Bureau Veritas had found any evidence to implicate any of the electrical appliances elsewhere in the kitchen (namely, the washing machine, sandwich maker, kettle, toaster, microwave and smoke detector) in the start of the fire.
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