Grenfell Tower Inquiry: Phase 2 Report · 2024
Chapter 44: Lifts
Chapter 44: Lifts
Introduction
¶44.1 During Phase 1 there was evidence that in the early stages of the fire the firefighters had been unable to secure control over the lifts in Grenfell Tower. That meant that the they had been unable to use the lifts in their firefighting and search and rescue operations; it also meant that some occupants of the tower were able to use the lifts in an attempt to escape.1545 Phase 1 Report Volume IV paragraph 33.13. The inability of the firefighters to bring the lifts under their control is therefore relevant to the circumstances in which some residents died1546 Phase 1 Report Volume IV paragraph 28.11. and it is therefore necessary to consider why the firefighters were not able to bring the lifts under their control on the night of the fire.
Background
¶44.2 In 2005, the lifts serving Grenfell Tower were substantially refurbished and many of their components were replaced. At that time the lifts served only the ground floor, the walkway floor (floor 2) and what became floors 4 to 23.1547 {TMO00853783/16}. As part of the refurbishment new flats were created on what became floors 1, 2 and 3. To accommodate those new flats it was necessary to extend service of the lifts to floors 1 and 3.1548 Phase 1 Report Volume I paragraphs 6.38-6.39. The extent of that work, which was carried out between 2014 and 2015, seems to have been limited to creating two new lift openings and landing entrances and associated work, such as reprogramming of the software.
¶44.3 Over the course of time there have been developments in the specifications of lifts installed in high-rise buildings. A fireman's lift is one that is designed to enable firefighters to take control of it when responding to a fire in the building. A firefighting lift has a higher specification and is designed to transport firefighters and their equipment to the scene of a fire with the minimum amount of time and effort. It is fitted with a higher level of equipment and structural protection, a communication system and a secondary back-up power supply. Much evidence was heard about whether the lifts at Grenfell Tower were fireman's lifts or firefighting lifts and, if they were fireman's lifts, whether they could or should have been upgraded to firefighting lifts. For present purposes, however, only two points need to be made: first, at no stage were the lifts firefighting lifts, as they did not possess all the features of firefighting lifts required by the relevant contemporaneous standards;1549 BS 5588-5: 1991, BS EN 81-72: 2003 and BS 5588-5: 2004. The lifts did not have many of the important features of a firefighting lift including, for example, a secondary power supply, water protection or a trap door. secondly, there is not enough evidence to enable us to determine whether it was reasonably practicable at any stage to upgrade the lifts so that they had at least those features of firefighting lifts that the physical constraints of the building would allow.
168The fire control switch
¶44.4 There were two fire control switches at Grenfell Tower, one on the ground floor and one on floor 2 (the Walkway floor). The switch on the ground floor appeared older and at the time of the fire was connected, whereas the switch on floor 2 appeared newer but was not connected.1550 {MET00019973/19-21}.
¶44.5 Email correspondence between Janice Wray and Claire Williams on 18 August 2014 showed that the entrance to the tower had been moved temporarily from the ground floor to the Walkway level.1551 {CST00001858}.
¶44.6 In his Record of Significant Findings dated 17 October 2014 Carl Stokes noted that the entrance to the building had been moved to the Walkway level and asked whether the fire service override controls for the lifts had been moved.1552 {CST00001734/7}. In his Record of Significant Findings dated 26 April 2016 he asked whether the controls for the lifts had been moved back down to street level.1553 {CST00002206/6}. A spreadsheet that appears to be dated October 2016 states that he had received confirmation the controls had been moved back down to street level.1554 {CST00000196/25-27}.
¶44.7 It is likely, therefore, that a new fire control switch was installed temporarily on floor 2 during the refurbishment in about August 2014. The switch on floor 2 was subsequently disconnected and the switch on the ground floor reconnected when the entrance was moved back to the ground floor. It is likely that that took place after April 2016, but it is difficult to be any more precise.
Maintenance and testing of the lifts
¶44.8 In the years before the fire the TMO produced various policies relating to lift safety, lift breakdowns and lift trap-ins.1555 {TMO00899279}; {TMO00899287}; {TMO00880413}; {TMO00880416}; {TMO00880418}; {TMO00880419}. Those published after 2011 required a lift engineer to carry out periodic visual checks of safety gear and other equipment, such as emergency alarms, emergency car lighting and lift machine room emergency lighting, in accordance with statutory regulations. The policies also required all lifts, hoists, disabled people's hoists and stairlifts to be inspected periodically by a competent engineer as required by statutory regulations, British Standards and manufacturers' instructions, and inspections to be recorded.1556 See, for example, clause 10.0 in {TMO00880416/6}.
¶44.9 The policies also required checks to be carried out by staff, including the TMO's senior lift engineer. He was directed to carry out checks on safety gear, emergency alarms, emergency car lighting and lift machine room emergency lighting in accordance with regulations. Monthly checks of all fireman's switches were required.1557 {TMO00880421/30}; {TMO00880422/30}; {TMO00880423/30}; {TMO00880430}; {TMO00880430/30}. Responsibility for those checks passed to the TMO's lift maintenance contractor in January 2014.1558 {TMO00880432/26}; {TMO00880430}.
¶44.10 The TMO also published a "Lift Safety (Passenger, Goods, and Fireman's) Policy and Procedure" dated 23 September 2013.1559 {TMO00880431}. It stated that lifts should be thoroughly examined by a competent person, usually an insurance engineer, every six months and that a lift maintenance contract should be established with a competent lift maintenance company. The policy also required lifts to be checked weekly or monthly to ensure that they were operating correctly.1560 TMO Lift Safety (Passenger, Goods and Fireman's) Policy Procedure Clause 3.23 {TMO00880431/3}.
169¶44.11 The TMO also produced a "Lift Safety Policy and Procedure" dated February 20141561 {TMO00880433}. which dealt with statutory inspections and maintenance. Section 4.1, relating to planned preventative maintenance, stated that the TMO should appoint a competent lift contractor to carry out monthly maintenance checks on all lifts, to record maintenance on the lift log card and to carry out maintenance identified by inspections as soon as practicable. The policy also noted that that was to be supplemented by regular inspections of the lift cars by the estate staff and health and safety staff. Section 4.2 provided that the lifts should be thoroughly examined every 6 months.1562 {TMO00880433/3-4}. Subject to various minor changes, the substance of the policy remained in place until the fire.
The PDERS maintenance contract
¶44.12 PDERS (an unincorporated trading division of Otis Ltd) was the TMO's planned preventative maintenance provider from 3 February 2014.1563 Fallis-Taylor {PDR00000050/2} page 2, paragraph 9.
¶44.13 Based on the Description of the Works contained in paragraph 2.0 of the document entitled "Service Information and Preambles for the Lift Preventative Planned Maintenance and Repair Contract",1564 {PDR00000049/43} paragraph 2.0. PDERS was expected to provide fully comprehensive servicing of the lifts throughout RBKC's estate, including routine inspection, maintenance and repairs. Breakdown response repairs due to vandalism or misuse were not included. The contract required maintenance visits to take place monthly with a minimum period between visits of not less than 21 days.1565 {PDR00000049/44} paragraph 2.1.1.
¶44.14 The contract identified the maintenance tasks and how often they should be carried out. Codes designated the frequency of a task, so, for example, "M1" indicated that a task should be carried out monthly, "M2" that it should be carried out every two months, and so on.1566 {PDR00000049/45} paragrapgh 2.1.9. Under the heading of "Landing Entrances" the contract expressly provided that fireman's control switches should be checked monthly.
¶44.15 The contract listed the lifts at Grenfell Tower (H090 and H091) and provided that a minimum of two hours should be spent each month on the maintenance of each of them.1567 {PDR00000049/82}. The evidence of Mark Wallis, a maintenance engineer at PDERS, was that a maintenance visit normally took about two hours for each lift.1568 Wallis {Day163/86:21-25}.
Maintenance by PDERS
¶44.16 The service visit reports for lift H090 covering the period from February 2014 until the fire1569 {PDR00000047}. suggest that it suffered no significant defects. The repair visit reports1570 {PDR00000048}. also reveal no noteworthy problems with it.
170¶44.17 Similarly, the service visit reports for lift H091 covering the period between February 2014 and June 20171571 {PDR00000041}. show no significant faults. The repair visit reports for lift H0911572 {PDR00000045}. also disclose no significant problems.
Testing by Bureau Veritas
¶44.18 Bureau Veritas is a testing, inspection and certification organisation which tests equipment, including lifting equipment, to assess whether it meets required technical standards.1573 Veitch {BVL00000006/1} page 1, paragraph 2.
¶44.19 Bureau Veritas was engaged by RBKC from January 2013 to carry out "thorough examinations" of all the lifts in the borough every six months, including those at Grenfell Tower.1574 Veitch {BVL00000006/8} page 8, paragraph 29. A thorough examination is a detailed examination of a lift and its associated equipment. It does not include maintenance or repairs.1575 Veitch {BVL00000006/2-3} pages 2-3, paragraph 5.
¶44.20 The reports of the inspections carried out by Bureau Veritas in 2016 and 2017 were available to us. They identified some category A defects (defects that are or could become a danger to users), some category B defects (defects that do not affect safety but usually require some maintenance) and some category C defects (defects that call for observations or recommendations only).1576 Lasisi {BVL00000015/2-3} pages 2-3, paragraphs 7-10.
¶44.21 On 7 January 2016, a Bureau Veritas engineer examined lifts H0901577 {MET00036488}. and H091.1578 {MET00036489}. He found no category A defects but several category B and C defects. On 2 June 2016, Bureau Veritas examined lift H0901579 {MET00035852}. and lift H091 again.1580 {MET00035853}. Again, no category A defects were found but several category B and C defects were identified.
¶44.22 On 2 November 2016, Isiaka Lasisi of Bureau Veritas examined lifts H0901581 {BVL00000014}. and H091.1582 {BVL00000016}. Although a category A defect was found in the latter, it did not relate to its fire safety features.1583 Lasisi {BVL00000015/5} page 5, paragraph 19. The evidence shows that on 2 November 2016 the TMO raised the category A defects with PDERS and on 3 November 2016 an engineer examined the lifts and rectified them.1584 {MET00036245}
¶44.23 Michael Arnold of Bureau Veritas examined lifts H090 and H091 on 10 April 2017.1585 {BVL00000008}. Although he identified some category B defects, he found no category A defects. As no category A defects had been identified during the visit on 10 April 2017 and there is nothing to suggest that the inspection was anything other than diligent, we conclude that there were no significant defects in the lifts at the time of the fire.
171Maintenance and testing of the fire control switch
¶44.24 Although until January 2014 the TMO's policies (in draft from August 2011 and approved in June 2012) provided that its own lift engineer would test the fireman's switch each month,1586 {TMO00880421/30}; {TMO00880430/30}. there is no evidence that the TMO did carry out any testing or maintenance of the fire control switch itself. PDERS said that the switch had been tested monthly from 2014 onwards, as the contract required. Although before that date the TMO's policies required it to be tested by its own lift engineer, it was not done regularly or, it seems, at all.1587 Cahalarn {Day164/68:12-19}; {Day164/69:1}; {Day164/70:3}.
The lift maintenance contractor - PDERS
¶44.25 Not all the lifts maintained by PDERS had fire control switches and it was therefore decided not to include the fire control switch in the report forms.1588 Fallis-Taylor {PDR00000050/6-7} pages 6-7, paragraph 25; Wallis {PDR00000036/3} page 3, paragraph 12. As a result, none of the service visit reports produced by PDERS1589 {PDR00000047}; {PDR00000041}. records testing of the fire control switch and there is no other written record of its having tested the switch.
¶44.26 From September 2016, Dave Smalley was the PDERS lift maintenance engineer for the North Kensington area, which included Grenfell Tower. He said that the fire control switch had been tested on each of his service visits in November and December 2016 and January and March 2017. He did not recall any problems with it.1590 Smalley {PDR00000029/5} page 5, paragraphs 25-28.
¶44.27 From April 2017, Mark Wallis was the lift maintenance engineer for Grenfell Tower. He carried out service visits on 12 April 20171591 {PDR00000047/34}; {PDR00000041/36}. and 9 May 2017.1592 {PDR00000047/35}; {PDR00000041/37}. He said he specifically remembered checking that the fire control switch had been in good working order on both occasions.1593 Wallis {PDR00000036/3} page 3, paragraph 12; {PDR00000036/5-6} pages 5-6, paragraphs 22-23; Wallis {Day163/115:9}-{Day163/116:5}. However, after he had given evidence, a CCTV recording made on 9 May 2017 was obtained which covered his maintenance visit. It showed clearly that, contrary to his evidence, he had not tested the fire control switch on that occasion. In the light of that recording Mr Wallis accepted that he had not tested the switch on that day.1594 Wallis {PDR00000056/1} page 1, paragraph 2. No CCTV recording of his visit on 12 April 2017 or, if he attended, of any previous visit was available, so we cannot be confident that he tested the control switch on that occasion or on any previous visit.
¶44.28 In the circumstances, there is no reliable evidence of when the fire control switch was last tested by PDERS before the fire. In fact, the weight of the evidence suggests that the fire control switch was not regularly tested before 14 June 2017.
The insurance inspections - Bureau Veritas
¶44.29 The Bureau Veritas reports from 2016 and 20171595 {MET00036488}; {MET00036489}; {MET00035852}; {MET00035853}; {BVL00000014}; {BVL00000016}; {BVL00000008}. record only defects affecting the lifts, not the testing of the fire control switch.1596 Lane, The Management and Maintenance of Grenfell Tower - Chapter 7 - KCTMO's duty to provide a suitable system of maintenance for fire protection measures {BLARP20000033/463} paragraph 19.5.47.
172¶44.30 Michael Arnold, the engineer who tested the lifts on 10 April 2017, confirmed that he had tested the fire control switch at Grenfell Tower. The outcome of the test was not separately documented, but we were told that if the switch had been defective, that would have been recorded in the Report of Thorough Examination.1597 Arnold {BVL00000017/5} page 5, paragraph 6c; Arnold {BVL00000019/2-3} pages 2-3. There is no such record. Accordingly, the insurance inspections found nothing to suggest that the fire control switch was not working effectively.
The London Fire Brigade
¶44.31 For the sake of completeness, we note that the LFB made a number of visits to Grenfell Tower.1598 {TMO00855611}; Ramsey {LFB00083855/3} page 3, paragraph 9; Ramsey {MET00071003/10} page 10; Ramsey {Day147/31:7}-{Day147/32:1}; Stokes {Day138/5:20}-{Day138/6:12}; McHugh {LFB00091787/12} page 12, paragraph 28. The last took place on 27 March 2017 and was carried out by Dean Ricketts and a crew from North Kensington fire station.1599 Ricketts {LFB00004825/4} page 4. He recalled that he had been told by one of his crew that the lifts had "fireman's lifts" controls but due to the number of people using the lifts they were unable to test them.1600 Ricketts {LFB00004825/5} page 5.
Automatic fire alarm recall
¶44.32 An automatic fire recall function was installed in about March 2006. Although there is evidence that the system was tested in 2013 and early 2014,1601 Howkins, Supplementary Report concerning the lifts at Grenfell Tower {RHO00000005/35-36} paragraphs 92-94. correspondence from September 2015 suggests that by then it had been disconnected. We do not know when that happened or who disconnected it.1602 Howkins, Report concerning the lifts at Grenfell Tower {RHO00000003/177-179} paragraphs 437-449. Investigations carried out after the fire also showed that there was no connection between the fire alarm, the smoke detection system and the lifts.1603 {MET00018469/11}; {MET00065879/34-35}; {MET00072161/12}; {MET00072161/26}.
The failure of the fire control switch
¶44.33 As set out in the Phase 1 report, the firefighters who attended Grenfell Tower on the night of the fire were not able to operate the ground floor fire control switch.
¶44.34 The first person to attempt to use the switch was CM Christopher Secrett. A CCTV recording shows him inserting a drop key into the switch at 01.01.1604 {INQ00000138}. He put the drop key into the fire control switch and felt the end of it drop down and engage but it did not work. He felt that the key was hitting some sort of stop. He turned the key several times in both directions but it did not operate the switch. He tried to turn it with more force but it made no difference. Eventually he tried to take the key out of the box but it was stuck. He left the key in place and tried to use the lifts in the normal way.1605 Secrett {MET00039598/3} page 3; Secrett Phase 1 {Day16/192:23}-{Day16/193:6}.
¶44.35 CM Secrett had bought a new drop key on 27 April 2017 on eBay. He kept it in a pocket of his tunic. He wore the tunic on the night of the fire but he could not be sure that the key he had bought on eBay was the key he had used on the night of the fire as the keys all look alike to the naked eye and it is common for keys to be switched and replaced.1606 Secrett {MET00056990/2} page 2.
173¶44.36 A CCTV recording shows that at 01.33 CM Ben Gallagher tried to use the fire control switch. A key was already in the box which CM Gallagher tried to use to take control of the lift. However, he was unable to activate the switch and left the key in place.1607 Gallagher {MET00040215}.
Evidence recovered after the fire
¶44.37 Another CCTV recording showed FF Nuttall removing the drop key from the fire control switch. He was unable to remember doing so and explained that, some two years after the fire, he had been called by a member of the LFB's investigation team and asked if he had any drop keys. FF Nuttall said that he had posted to them the one drop key that he had been able to find, although he had thought he had two. He was not able to say that the key that he had provided to the investigation team was the one that he had removed from the tower.1608 Nuttall {MET00056991/1} page 1.
¶44.38 It is not possible to say whether the key sent in by FF Nuttall had been used on the night of the fire. The period between the fire and the posting of the key was very long and FF Nuttall accepted that he might have swapped the key with another firefighter.1609 Nuttall {MET00056991/2} page 2.
¶44.39 The Metropolitan Police instructed an engineering consultant, WSP, to visit Grenfell Tower on 15 March 2018 to conduct a visual inspection of the fire control switch on the ground floor. The engineer who attended noted that it had not been damaged by fire or water and therefore recommended that it be removed for examination.1610 {MET00019973/12} paragraph 6.1. The fire control switch therefore remained in place from the date of the fire until about March 2018.
Why did the switch fail to operate?
Presence of debris
¶44.40 The first possibility is that the switch was jammed with debris. It was first tested on 18 April 2018 in the presence of professional engineers from WSP, Elan Lifts, the Metropolitan Police, the LFB and an independent lift test engineer.1611 {MET00019973}. The report of the test made by WSP recorded that the switch was difficult to operate. The faceplate was removed to determine the reason why the switch could not be operated and the mechanism was found to be seized and deformed.1612 {MET00019973/21}.
¶44.41 The report also concluded that, as the mechanism of the switch was defective, it had not been examined by the lift service company at regular intervals.1613 {MET00019973/43} paragraph 10.1.
¶44.42 The switch was tested again on 15 February 2019 at the Building Research Establishment (BRE). The test is described in two reports: the first written by Arup,1614 {RHO00000001}. the second by André Horne, an independent expert instructed by the Metropolitan Police.1615 {MET00056700}. In both reports the switch is described as Exhibit BJG/74.
¶44.43 There is no evidence that the switch was cleaned between the test on 18 April 2018 and that on 15 February 2019. However, it had been moved between locations, so it is possible that any debris that had originally been inside it had moved or had been dislodged.
174¶44.44 Arup's report is dated 1 March 2019. It stated that a visual examination of the switch disclosed a build-up of builders' material on the casing and that the micro-switch was jammed. The author's impression was that the debris was wall plaster. On examination, the micro-switch became free and worked. The cause of the jamming could not be identified, but there were plaster grains on the work bench. The author's view was that the presence of builders' material had not been the result of disturbance when the switch was extracted but from the original works.1616 Howkins, Grenfell Tower Lifts Briefing Note regarding fire control switches {RHO00000001/13}.
¶44.45 André Horne's report was based on the same test. He said that the switch frame arms were jammed because of debris on the frame which appeared to be dirt, mortar or sand, possibly from the construction of the building. Mr Horne could not say whether some of the debris had been dislodged during the removal, transportation and storage of the switch, thereby causing the jam, or if it had been jammed before its removal. After some gentle manipulation by hand, it moved freely. In Mr Horne's view, forceful manipulation of a correctly fitting key would have moved the switch frame arms.1617 {MET00056700/3}.
¶44.46 Mr Howkins was also present at the test on 15 February 2019. He provided a diagram which showed where the debris had been observed.1618 Howkins, Supplementary Report concerning the lifts at Grenfell Tower {RHO00000005/48}. He originally estimated the quantity of debris removed as about a quarter of a teaspoonful,1619 Howkins, Supplementary Report concerning the lifts at Grenfell Tower {RHO00000005/48} paragraph 161. but in his evidence he said that it had been half to three-quarters of a teaspoonful.1620 Howkins {Day165/103:5-10}. There was no way of knowing if the switch had become jammed with debris while it was still in place, during its removal, while it had been stored or in the course of transportation before testing.
¶44.47 During the test a drop key was inserted into the switch. The switch did not immediately operate but after the key had been turned left and right a few times the debris on the micro switch cleared and it was possible to operate the switch.1621 Howkins, Supplementary Report concerning the lifts at Grenfell Tower {RHO00000005/48} paragraph 159. Mr Howkins and Mr Horne agreed that the use of a reasonable amount of force would probably have cleared the debris.1622 Howkins, Supplementary Report concerning the lifts at Grenfell Tower {RHO00000005/49} paragraph 163.
¶44.48 Both Mr Horne and Mr Howkins noted another abnormality in the switch, unrelated to the debris, namely that the side wards were bent out of shape. That was not specifically noted in WSP's report, but the reference to the mechanism being "deformed" may have been a reference to the bent side wards.1623 {MET00019973} page 21.
¶44.49 The Arup briefing note also noted the deformation of the side wards and photo 13 in the report showed the damage.1624 Howkins, Grenfell Tower Lifts Briefing Note regarding fire control switches {RHO00000001/8-9}. The author concluded (and Mr Horne agreed)1625 {MET00056700/3}. that the damage to the side wards had been caused either by the use of an incorrect drop key, which deformed the side wards, or by a drop key being inserted too far into the barrel with the result that a high twisting force damaged the side wards.1626 Howkins, Grenfell Tower Lifts Briefing Note regarding fire control switches {RHO00000001/13}.
Use of an incorrect key
¶44.50 The second possibility is that the drop key used was not the right one for the fire control switch.
175¶44.51 The LFB purchased drop keys for fire stations which were made available through its internal supply system. The LFB has used the same supplier of lift keys since at least 2011.1627 Atkinson {LFB00083885/2} page 2, paragraph 6; Atkinson {LFB00083885/8} page 8, paragraph 11.
¶44.52 Drop keys are not issued to individuals but are kept on the pumps with many other keys and are used by all crew members as necessary. If a key is lost and a replacement needs to be ordered using the LFB's internal system, it can take up to four weeks to arrive. For that reason, firefighters often buy their own drop keys from suppliers such as Amazon or through eBay.1628 Secrett {MET00056990}; Secrett {LFB00091726/2-3} pages 2-3, paragraphs 7-8.
¶44.53 The drop key obtained from FF Nuttall was labelled LJH/67 by the police. It is not possible to know whether it was the one used on 14 June 2017.1629 Nuttall {MET00056991}. It was tested on 29 July 2019 at BRE Watford. In his subsequent report Andre Horne noted that because of its dimensions it could not be used in the fire control panel at the tower or in the example panel provided by the Metropolitan Police for the purposes of the examination.1630 {MET00056700/4}. The key could be inserted into the opening of the switch but could not be turned and therefore could not have caused the damage to the side wards.
¶44.54 A key supplied by Jeff Turner, a forensic locksmith, fitted the switch taken from the tower correctly. An example key provided for the purposes of the examination was also tested but did not fit correctly.1631 {MET00056700/3}.
¶44.55 Further testing took place on 7 February 2020.1632 {MET00071006/1}. For that purpose two more keys were compared. Key DER/22 was one of a set of keys provided by the LFB that had been assembled from keys left over from various appliances no longer in use and included a drop key.1633 Wilson {MET00077769/2}. It did not fit very well in the switch taken from the tower and Mr Horne noted that, even if the side wards had been straight, it would still not have fitted correctly. However, Key DER/22 did fit normally in the example panel and could operate the panel taken from the tower if sufficient force was applied.1634 {MET00071006/3}.
¶44.56 Key SJG/01 had been bought on eBay. It fitted both the switch taken from the tower and the example switch.1635 {MET00071006/4}.
¶44.57 By contrast, the key obtained from FF Nuttall could not be used to operate either switch. The only keys that functioned normally in the switch taken from the tower were the key bought on eBay (SJG/01) and the key provided by Jeff Turner. Neither the example key nor the key provided by the LFB (DER/22) fitted the switch taken from the tower correctly, but, if sufficient force had been applied, they could both have operated it. All the keys other than LJH/67 worked properly in the example fire control panel.
An unidentified fault
¶44.58 It is possible that some other unidentified cause was responsible for the failure of the fire control switch to work on the night of the fire, but there is no evidence that the switch had been damaged by smoke or fire and no other defects in it were identified.
176¶44.59 We think that the use of the wrong size of drop key is the most likely reason for the failure of the fire control switch to operate properly on the night of the fire.1636 Howkins {Day165/112:5-7}.
Conclusions
¶44.60 Two important matters emerge from this aspect of our investigations. The first is the need for regular maintenance of fire control switches. Whether debris in the switch box interfered to any significant extent with the operation of the switch on the night of the fire, the likelihood is that more foreign material was present than should have been allowed to accumulate in a piece of equipment that was supposed to be checked at regular intervals. We cannot say that a failure of regular maintenance was the cause of the switch becoming inoperable, but we can say that the evidence strongly suggests that it was not given the attention it deserved.
¶44.61 The second concerns the significant variation in the dimensions of the drop keys tested and their compatibility with different fire control switches. One might have expected fire control switches to conform to a specified pattern and that drop keys would likewise conform to a pattern known to be capable of operating the standard switch. That appears not to have been the case. As a result, it appears to have been largely a matter of chance whether the key carried by the first firefighter who tried to take control of a lift enabled the switch to be operated. That is a recipe for disaster. Part of the reason for that unsatisfactory state of affairs lies in the practice of firefighters' obtaining drop keys from various sources without appropriate guarantees of their suitability. Standardisation and control of equipment by fire and rescue services are necessary to avoid incompatibility. On 8 August 2019, the LFB notified all watch managers and crew managers that keys purchased from external sources were in circulation and instructed them to carry out an immediate physical check of all drop keys to ensure that keys of the correct pattern were stowed on all firefighting appliances at all stations.1637 Atkinson {LFB00083885}; also see {LFB00083895}. We hope that as a result the substantial variation in the keys used by firefighters has now been eliminated.
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