Chapter 45: Emergency planning

Legislative framework and guidance

¶45.1 Save for the purposes of article 30 (which is not relevant for present purposes), the Fire Safety Order does not apply to domestic premises. Each flat in Grenfell Tower was occupied under a separate lease or tenancy agreement and so constituted domestic premises for the purposes of the Order. Accordingly, as far as the residents were concerned, the duties imposed by articles 8 to 22 applied only in relation to the common parts of the building, namely, the lobbies, lifts and staircase.

¶45.2 Article 14 imposes a duty to ensure that routes to emergency exits and the exits themselves are kept clear at all times; emergency routes and exits must be indicated by signs and be adequately lit (including, where necessary, by emergency lighting). Article 15(1)(a) requires the responsible person to establish, and where necessary give effect to, appropriate procedures to be followed in the event of serious and imminent danger from fire and to nominate a sufficient number of competent persons to implement those procedures in so far as they relate to the evacuation of relevant persons from the premises. The procedures must, so far as is practicable, require any relevant persons exposed to a serious and imminent danger to be informed of the nature of the hazard and of the steps taken or to be taken to protect them from it (article 15(2)(a)).

¶45.3 In practical terms the Fire Safety Order required the TMO to ensure that the lift lobbies, the lifts themselves and the staircase were kept free of obstructions, were properly lit (including by emergency lighting when necessary) and displayed appropriate signs to indicate the escape route. It appears to assume that the occupants of any flat in which a fire occurred, or which was affected by heat or smoke from a fire in a neighbouring flat, could escape into the lobby and from there make their way to safety using the stairs. It did not, however, impose a duty on either of them to devise a plan to evacuate residents from within their flats, much less a plan to evacuate the building as a whole. A "stay put" or "defend in place" strategy for responding to a fire is better viewed as a response strategy rather than an evacuation plan.

¶45.4 Publicly available guidance, in particular the guidance published by the Local Government Association specifically in relation to purpose-built blocks of flats (the LGA Guide), emphasised the need to ensure that that information about the procedure to be followed in the event of a fire should be disseminated to all residents.¹⁶³⁸¹⁶³⁸ {HOM00045964/115-117} paragraphs 77.1 to 77.6; {HOM00045964/133} Appendix 1.

¶45.5 Section 79 of the LGA Guide, under the heading "Preparing for emergencies", advised that there must be a suitable emergency plan for the premises, but that, in the case of purpose‑built blocks of flats, that would rarely require more than a fire action notice, which in most cases would be sufficient as an emergency plan. It also recognised that it was common to communicate the emergency plan to tenants in other ways, so that it was not always necessary to display a fire action notice in the building.¹⁶³⁹¹⁶³⁹ LGA Guide {HOM00045964/118} paragraph 79.1.

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¶45.6 With the approval of the LFB, both before and after the refurbishment Grenfell Tower was subject to a "stay put" strategy, under which residents were encouraged to remain in their flats unless they were directly affected by fire or smoke because that was considered to be the safest course for them to take. Any more general evacuation of the building was expected to be directed and supervised by the fire and rescue service. There was therefore no need for the responsible person to create an evacuation plan for the building as a whole. We consider below the steps taken by the TMO to inform residents of the steps to be taken in the event of a fire in the building.

The TMO Emergency Plan

¶45.7 The TMO maintained an Emergency Plan. It had been drafted in August 2004 and revised in October 2006, May 2009, November 2009 and February 2016.¹⁶⁴⁰¹⁶⁴⁰ TMO Emergency Plan – Version 1 August 2004 {TMO10013898}; TMO Emergency Plan – Revised October 2006 {TMO10048195}; TMO Emergency Plan – Revised November 2009 {TMO00841015}; TMO Emergency Plan – Revised 2016 {TMO10013898}. The 2016 version referred to revisions in May 2009 and May 2015, but these have not been disclosed to the Inquiry. Adrian Bowman was responsible for maintaining, and when necessary revising, it under the general supervision of Janice Wray.¹⁶⁴¹¹⁶⁴¹ Wray {Day142/34:23-25}. She was unable to say what had given rise to the various revisions, but accepted that there had been no system for reviewing it at regular intervals and making any necessary changes.¹⁶⁴²¹⁶⁴² Wray {Day142/36:20}-{Day142/38:3}. That, of itself, was a serious failing, because, if a plan is not reviewed regularly, it may not be fully effective when an emergency occurs.

¶45.8 The chairman considered the TMO Emergency Plan in the Phase 1 report and found that it was far from adequate.¹⁶⁴³¹⁶⁴³ Phase 1 Report, Volume IV, paragraph 30.93. The evidence we have heard at Phase 2 only reinforces that conclusion. The TMO Emergency Plan was in two parts: the first was the generic plan; the second contained separate sections relating to the various properties managed by the TMO, each containing a description of a particular property.

¶45.9 The section relating to Grenfell Tower was dated 25 February 2002.¹⁶⁴⁴¹⁶⁴⁴ November 2009 TMO Emergency Plan {TMO00841015/147}. It contained estimates of the number of residents and vulnerable persons; it identified places where the emergency services could gather and identified a nearby place of shelter. There was information about the electricity, gas and water supplies and the dry riser. The location of the keys was also recorded and the means of escape. The "stay put" strategy was recorded as was the existence of automatic fire alarm and smoke extract systems, but no further information was provided about them.¹⁶⁴⁵¹⁶⁴⁵ November 2009 TMO Emergency Plan {TMO00841015/147-148}.

¶45.10 The version of the Emergency Plan dated February 2016 was current at the date of the fire. The sub-section relating to Grenfell Tower was largely the same as that which had been created on 25 February 2002, 15 years earlier. Janice Wray was unable to explain why that was the case. The number of dwellings had not been changed to reflect the new flats created in the lower floors as a result of the refurbishment, but the place of shelter had been changed to North Kensington Resource Centre. The means of escape were still described as through the stairs and onto the walkway level, which did not reflect the fact that the door to the walkway had been blocked up during the refurbishment. The section containing "other information" had only partly been brought up to date. Information about the reception desk, the creche and the boxing club had been removed as well as information about the hydraulic lift to social services on the first floor. A description of the bin stores was included and a note recorded about a fire that had affected them in 1997. However, the plan still recorded that there was an automatic fire alarm and smoke extract system, even though the former no longer existed. The plan noted that in case of fire residents were advised to remain in their homes unless affected by heat or smoke.¹⁶⁴⁶¹⁶⁴⁶ February 2016 TMO Emergency Plan {TMO10013898/145-146}.

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¶45.11 The piecemeal and inconsistent revision of the information in the Emergency Plan meant that that part of the plan could not safely be relied on in an emergency at Grenfell Tower.

¶45.12 Janice Wray told us that the Emergency Plan had been intended to deal with only minor emergencies, such as a fire, a power failure, a leak or a flood.¹⁶⁴⁷¹⁶⁴⁷ Wray {Day142/38:5-19}; {Day142/40:22}-{Day142/41:19}. That was because the TMO lacked the resources to respond to a major emergency. RBKC had a more comprehensive emergency plan and greater resources. The plan itself, however, said that it set out the roles and responsibilities of the TMO in the event of a major incident, which it defined as an incident or natural disaster resulting in death, injury or serious disruption to normal life of a magnitude that would acutely stretch the TMO's resources.¹⁶⁴⁸¹⁶⁴⁸ February 2016 TMO Emergency Plan {TMO10013898/13}.

¶45.13 Ms Wray said that the section on Grenfell Tower had been intended to collate information that the emergency services or anybody else might require for the purposes of emergency planning,¹⁶⁴⁹¹⁶⁴⁹ Wray {Day142/43:22}-{Day142/44:2}. but she appears not to have given any thought to whether it contained all the information recommended by the guidance. They referred only to the requirement to communicate the emergency plan (that is, the "stay put" strategy) which they did through the residents' handbook, Link magazine and in documents provided to residents when they signed the tenancy agreement with the TMO.¹⁶⁵⁰¹⁶⁵⁰ Wray {Day142/45:5}-{Day142/46:1}.

The fire safety strategy

¶45.14 The TMO's fire safety strategies of 2013 and 2016 did not refer to the Emergency Plan,¹⁶⁵¹¹⁶⁵¹ 2013 TMO Fire Safety Strategy {TMO00830598}; 2017 TMO Fire Safety Strategy {TMO00847324}. but that may have been because it was understood that the Emergency Plan was intended as a response to a wide range of emergencies.

¶45.15 The 2013 fire safety strategy asserted that a "stay put" or "defend in place" strategy was "overwhelmingly" appropriate for the TMO's housing blocks. That was because compartmentation, both between flats and also between flats and the common parts, was considered to be sufficient to withstand fire for long enough to enable the fire and rescue service to attend and extinguish it. That message was said to have been communicated to residents in various ways, including in the resident's handbook, on the TMO's website and in Link magazine.¹⁶⁵²¹⁶⁵² {TMO00830598/10-11}, paragraph 15.1; {TMO00847324/10}, paragraph 15.2.

Evacuation planning in the fire risk assessments

¶45.16 A fire risk assessment should set out in detail the fire management procedures required to respond to a fire so that they can provide the basis of an appropriate response plan.¹⁶⁵³¹⁶⁵³ Lane, Chapter 8 – The adequacy of the advice provided by the fire risk assessor Carl Stokes of CS Stokes & Associates Ltd to KCTMO Report {BLARP20000027/373}. Clause 16 of PAS 79:2012 also required a fire risk assessor to undertake an assessment of fire safety management, which included procedures for people to follow in the event of fire, including people with special responsibilities, the nomination of people to respond to fire and, where appropriate, to assist with evacuation and arrangements for liaison with the fire and rescue service, both in respect of planning for fire and at the time of any fire.¹⁶⁵⁴¹⁶⁵⁴ PAS 79:2012 {CTA00000003/50}, paragraph ii.c-e. The commentary to clause 16 said that in making a fire risk assessment there was a need to ensure that there were formal, documented procedures of an adequate kind for people to follow in the event of fire. A list of procedures considered to be adequate was included.¹⁶⁵⁵¹⁶⁵⁵ PAS 79:2012 {CTA00000003/51}, paragraph viii.

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¶45.17 Carl Stokes did, in the main, take PAS 79:2012 as his guide for making fire risk assessments, although his adherence to it was patchy and inconsistent. Each of his fire risk assessments for Grenfell Tower had a section headed "The Evacuation Strategy for this building" in which he noted that there was a "stay put" strategy in place and that the fire and rescue service or the TMO would organise a general evacuation of the building, if appropriate. He also noted that the TMO had provided information to all residents in a tenant's handbook, letters and briefing sheets and in articles in Link.¹⁶⁵⁶¹⁶⁵⁶ Grenfell Tower Fire Risk Assessment – 20 June 2016 {CST00003145/6}. Once the refurbishment of the tower was under way, he recorded that the contractors had an evacuation policy and procedure relating to areas under their control and that the nursery and boxing club had their own fire risk assessments and evacuation procedures. He did not record whether there was an emergency plan specifically for Grenfell Tower that described how the TMO would contact the LFB, residents or the nursery or boxing club in the event of a fire. Nor did he record whether there was a plan which contained relevant information specific to the tower. That part of the fire risk assessment remained substantially the same between 2010 and 2016 with minor and immaterial variations.¹⁶⁵⁷¹⁶⁵⁷ Lane, Chapter 8 – The adequacy of the advice provided by the fire risk assessor Carl Stokes of CS Stokes & Associates Ltd to KCTMO Report {BLARP20000027/376}.

¶45.18 Carl Stokes told us that in the case of Grenfell Tower the evacuation plan had been a "stay put" strategy,¹⁶⁵⁸¹⁶⁵⁸ Stokes {Day136/223:3-6}; Letter from Carl Stokes to Janice Wray of 27 September 2010 {CST00003061}. information that he admitted he had obtained at a meeting with Janice Wray on 24 September 2010.¹⁶⁵⁹¹⁶⁵⁹ Stokes {Day137/16:6-11}. In his view, that explained why his fire risk assessments for many other high-rise residential blocks contained similar language. He had been responsible for the inclusion in his fire risk assessments of the statement that the Fire and Rescue Service or the TMO would organise a general evacuation of the building. He had not been told by Janice Wray that the TMO (either alone or in conjunction with the Fire and Rescue Service) would organise a general evacuation.¹⁶⁶⁰¹⁶⁶⁰ Stokes {Day136/221:15}-{Day136/222:3}; {Day137/4:3}-{Day137/5:18}; Wray {Day142/54:10}-{Day142/55:4}; {Day142/59:2-7}. He had based it on the knowledge that under GRA 3.2 it was something for which the fire and rescue service should have contingency plans and that the TMO was aware of the needs of individual residents.¹⁶⁶¹¹⁶⁶¹ Stokes {CST00003063/51} page 51, paragraph 150 (i). He thought that it was always possible that a situation might arise in which the fire and rescue service would have to evacuate the building. He said that he had not contemplated that the TMO would organise an evacuation in response to an emergency; in such cases it would act under the direction of the Fire and Rescue Service.¹⁶⁶²¹⁶⁶² Stokes {Day137/9:19-23}. It would do so only in cases where it had other reasons for evacuating the building and could do so in its own time.¹⁶⁶³¹⁶⁶³ Stokes {Day137/6:1-7}. However, those qualifications were not recorded in the fire risk assessment itself, nor were they readily apparent to anyone reading the document, which gives a quite different impression.¹⁶⁶⁴¹⁶⁶⁴ Stokes {Day137/9:24}-{Day137/10:4}.

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¶45.19 It was the TMO's responsibility to check the accuracy of the statements in Mr Stokes's fire risk assessments, since, under article 9 of the Fire Safety Order, they were its own assessments. We therefore find it difficult to understand why no one at the TMO took issue with an erroneous statement on a matter of such importance, particularly since it was repeated in fire risk assessments made in respect of other high-rise buildings, including Adair Tower, Gillray House, Hazlewood Tower and Markland House. However, as we have noted elsewhere, at no point during the seven years in which Carl Stokes carried out fire risk assessments for the TMO did Janice Wray seek to question any of his assessments whether in relation to Grenfell Tower or any other building.¹⁶⁶⁵¹⁶⁶⁵ Apart from a disagreement about whether the lifts at Grenfell Tower were fire-fighting lifts (see Chapter 44); and on his grading of remedial actions (see Chapter 39). She was clear in her own mind that the TMO had no formal role in organising an evacuation in the event of a fire, but she did not make that clear to Carl Stokes.¹⁶⁶⁶¹⁶⁶⁶ Wray {Day142/63:8-16}.

The fires at Adair Tower and Trellick Tower

¶45.20 In the two years before the Grenfell Tower fire there were two fires in high-rise residential buildings managed by the TMO. On 31 October 2015, a fire occurred in Adair Tower and on 27 April 2017 there was a fire in Trellick Tower.¹⁶⁶⁷¹⁶⁶⁷ LFB FSR Post Fire Review Report {LFB00054910}; LFB Senior Fire Safety Officers Report {LFB00001626}; Paper 3 – Adair Tower fire – 31 October (2015) dated 23 November 2015 {TMO00840431}. On both occasions, the LFB carried out a partial evacuation of the building.¹⁶⁶⁸¹⁶⁶⁸ Paper 3 – Adair Tower fire – 31 October (2015) dated 23 November 2015 {TMO00840431}.

¶45.21 Janice Wray was aware that on each occasion part of the building had been evacuated and knew that the "stay put" strategy had sometimes been departed from.¹⁶⁶⁹¹⁶⁶⁹ Wray {Day142/52:2-19}; {Day142/53:2-7}. On 23 November 2015, she drafted a note to the Health and Safety team about the Adair Tower fire in which she reported that there was a "stay put" strategy at Adair Tower, in common with most of the TMO's high-rise residential blocks. She said that the LFB would decide whether an evacuation was required and, if so, would carry it out. She also said that the LFB would be assisted by any TMO staff who were present.¹⁶⁷⁰¹⁶⁷⁰ Paper 3 – Adair Tower fire – 31 October (2015) dated 23 November 2015 {TMO00840431}. She described that as merely an observation on the response at Adair Tower rather than a plan.¹⁶⁷¹¹⁶⁷¹ Wray {Day142/63:2-7}.

The response of senior management to the fires

¶45.22 After the fire at Adair Tower on 31 October 2015, Robert Black asked Janice Wray and Sacha Jevans to explain the building's fire procedures and processes.¹⁶⁷²¹⁶⁷² Email from Robert Black "re Fire Adair Tower" dated 31 October 2015 {TMO00869147}. In response Janice Wray described the "stay put" strategy and explained that, if a fire occurred, the LFB would decide whether an evacuation was necessary and, if so, whether it should be partial or total.¹⁶⁷³¹⁶⁷³ Email from Janice Wray to Robert Black dated 31 October 2015 {TMO00869159}.

¶45.23 On 1 November 2015, Robert Black sent Peter Griffiths, Teresa Brown, Sacha Jevans and Yvonne Birch some complaints that Councillor Mason had received from the press and residents. They included the absence of an evacuation plan.¹⁶⁷⁴¹⁶⁷⁴ Email from Robert Black dated 1 November 2015 {TMO00866475}.

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¶45.24 On 2 November 2015, Robert Black told the board that the TMO had responded to the fire rapidly,¹⁶⁷⁵¹⁶⁷⁵ Email from Robert Black dated 2 November 2015 {TMO00866480}; {TMO10050075}. and following an inspection of Adair Tower on 3 November 2015 Carl Stokes expressed the view that the TMO's management procedures had worked well.¹⁶⁷⁶¹⁶⁷⁶ Initial views of the fire risk assessor following his inspection of Adair Tower on 3 November 2015 {CST00025017}. Robert Black told the Housing and Property Scrutiny Committee on 5 November 2015 that the emergency planning had worked and that the fire doors had also worked well,¹⁶⁷⁷¹⁶⁷⁷ Minutes of the Housing and Property Scrutiny Committee, 5 November 2015 {RBK00048049/6}. but that was not quite the message that was conveyed in internal meetings of the TMO that followed. The incident was discussed at an executive meeting on 11 November 2015.¹⁶⁷⁸¹⁶⁷⁸ TMO executive team meeting {TMO00843593/2}. Barbara Matthews, who was co-ordinating the response to the fire, said that although RBKC had been supportive, the TMO should be more involved in RBKC's emergency planning strategy so that everyone was aware of contact numbers and roles and responsibilities. The TMO's own Emergency Plan was discussed and it was agreed that the executive team should meet Janice Wray and Hash Chamchoun to gain a better understanding of who was responsible for keeping it up to date and for applying any lessons learnt from the fire at Adair Tower.¹⁶⁷⁹¹⁶⁷⁹ TMO executive team meeting {TMO00843593/2}.

¶45.25 As a result of the Adair Tower fire, it had become apparent to the TMO that its role in an emergency was unclear and that its Emergency Plan should be reviewed in conjunction with RBKC's emergency plan and revised as necessary.¹⁶⁸⁰¹⁶⁸⁰ Matthews {Day148/122:9-15}. Barbara Matthews may have looked at the plan,¹⁶⁸¹¹⁶⁸¹ Matthews {Day148/122:16-18}. but she did not take any steps herself to make sure that it was brought up to date; instead, she relied on Janice Wray to do that.¹⁶⁸²¹⁶⁸² Matthews {Day148/122:9}-{Day148/123:5}.

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