Grenfell Disaster

Since the tragic and horrific events of the Grenfell Tower fire in June 2017 the work of the inquiry has been widely reported and this month expert witnesses have been providing their final evidence.

Failings around the rainscreen panels fitted to the external walls have been widely reported and all that saw it were astounded and horrified to see the fire spread up and across the outside of the building on the night of the fire. The failure of the panels to restrict the spread of fire is known to be the main cause of the tragic deaths but the inquiry has revealed other shortcomings in fire safety at Grenfell Tower.

My blog here deals with those shortcomings that are related to the fire doors and draws on the findings of the expert witness Dr Barbara Lane. Her Module 3 report ‘The management and maintenance of Grenfell Tower: Chapter 11 Conclusion’ can be found here

Section 22 of the report is titled ‘Consequences of KCTMO’s fire risk management system – Fire Doors’.

With the aim of increasing fire door safety awareness generally, I have summarised some of the key findings of the report below.

Grenfell Tower was a 24-story residential tower block and contained many fire-resisting doors as the entrance to individual flats and in communal areas. The fire risk management system should provide for the fire doors to be subject to a suitable maintenance regime and kept in efficient working order and good repair. This is a legal requirement of Article 17 of The Regulatory Reform (Fire Safety) Order 2005 and article 17 of the Order can be found at

To achieve compliance with the Order at such a building housing so many people, maintenance of the fire doors would require a system involving multiple teams. This system of maintenance would include liaison with leaseholders and occupants regarding their flat entrance doors and this can be a time-consuming task requiring a suitable level of coordination. The fire doors in communal areas that protect stairs and lobbies are entirely under the control of the Responsible Person, this being the housing provider. In the case of Grenfell Tower, this means the Kensington & Chelsea Tenant Management Organisation (KCTMO). The KCTMO had primary responsibility for the protection of all relevant persons including occupants and leaseholders and the published guidance is clear that fire doors to flat entrances are critical to protect relevant persons.

Dr Lane’s report found that the most significant document in terms of arrangements for fire doors was the KCTMO Fire Safety Strategy which required that when a routine inspection found a defect with the fire door it was reported to Customer Service Centre who would instigate the repair. A sub-section of that document required that repairs to fire doors and self-closers be treated as a priority. Where repairs were required the Customer Service Centre passed these onto a repairs company.

The KCTMO Fire Safety Strategy set a performance standard for flat entrance doors but not for the fire doors to the protected stair. This performance standard played a significant role in the KCTMO’s later engagement with London Fire & Emergency Planning Authority (LFEPA) when they raised concerns about the KCTMO’s overall arrangements for fire doors at their buildings.

Dr Lane’s report states that many fire doors came to be in place without adequate self-closing devices. This, she says, was due to insufficient coordination between the different KCTMO departments. The work of the Customer Service Centre, the work of Mrs Wray (Health & Safety Manager) dealing with fire risk assessments and the work of the Estates Department dealing with routine inspections was not coordinated resulting in a failure to provide a planned maintenance regime supported by routine inspections and reactive repairs. As a result, there was no accurate information about the status of self-closer faults and failures. This being so, how could it be possible to assess risk to ‘relevant persons’ and to implement the necessary maintenance and repairs?

KCTMO’s failure to arrange for the installation of fire doors with the necessary fire performance

Between 2011 and 2013 KCTMO decided to carry out a programme of replacement of flat entrance doors to flats occupied by tenants. The Health & Safety Manager, Mrs Wray, relied on advice from the Fire Risk Assessor, Mr Stokes, when deciding which high-risk buildings were to have replacement flat entrance doors.

The guidance at the time, BS 8214:2008, LACoRS CST00002516 and BS 9991:2011 each stated that when installed every component of the fire door must comply with the tested specification and that any changes may significantly affect the fire performance of the door. Dr Lane found no evidence that the KCTMO appointed any party to check that the fire doors were installed in accordance with the relevant fire resistance performance test report. She goes on to conclude that there was no effective monitoring system resulting in the majority of the flat entrance door components installed being not being as those recorded in the relevant fire resistance performance test report.

Dr Lane opines that the new flat entrance doors represented a “significant change in the matters” as referred to by Article 9 of the Regulatory Reform (Fire Safety) Order 2005. The defects due to the different standards of door components installed were not identified in Mr Stokes subsequent fire risk assessments and neither were the defects identified through KCTMO’s arrangements to carry out routine inspections. However, it would require detailed training to make this a realistic expectation and no such training was undertaken. Therefore, KCTMO’s arrangements did not result in the specified fire performance standard.

KCTMO’s approach to the fire performance of leaseholder flat entrance doors

Leaseholder flat entrance doors were excluded from the replacement door programme. Understandably, leaseholders raised queries about this and extensive communications took place involving KCTMO, RBKC and LFEPA. However, in the case of Grenfell Tower Mr Stokes the fire risk assessor concluded the doors were so-called Notional Fire Doors with self-closing devices. Therefore, by means of arrangements for leaseholder doors made by KCTMO, no further action was taken. Dr Lane says that there is no evidence as to how Mr Stokes reached this conclusion as he did not methodically or routinely incorporate inspections of flat entrance doors into his work.

All leaseholder flat entrance doors were destroyed in the fire therefore, it was not possible to inspect the doors to confirm them as Notional Fire Doors with self-closers.

However, some leaseholder flat entrance doors had been identified as high-risk and were replaced. Mrs Wray reached this decision based on evidence provided by Mr Stokes. However, according to Dr Lane’s report, there are significant concerns that as Mr Stokes did not methodically inspect flat entrance doors this evidence was limited and at best an ad-hoc and random sample of building inspections.

In the event, only the doors listed as high-risk by Mrs Wray based on Mr Stokes’ evidence were replaced.

Dr Lane concludes that:

  • Mr Stokes had not assessed individual leaseholder flat entrance doors.
  • Flat entrance doors were not part of the routine inspection work of the Estates Department.
  • KCTMO could not, therefore, collate a complete list of high-risk leaseholder doors and was wrong to use the list as they did.
  • KCTMO were wrong to use the list as they did to confirm to LFEPA and the KCTMO board that the leaseholder doors issue had been resolved.

Dr Lane goes on to conclude that there was a substantial failure of KCTMO’s arrangements regarding both the quality of inspections & maintenance and the quality of their fire risk assessments which excluded fire door surveys. This is because neither set of arrangements allowed KCTMO to know whether the protective measures provided by flat entrance doors could be relied upon in terms of the ‘general fire precautions’ for Grenfell Tower.

The significance of the performance issues with the Manse Masterdor Fire Doors

There were warning signs about the quality of the flat entrance doors provided by the door replacement programme. Three recurring faults developed with the replacement doors at an early stage in the programme of works:

  • Failure of self-closing device fixings
  • Excessive force is required to open the doors
  • Mechanical faults with the self-closing devices

Manse Masterdor were aware of these issues and according to records in July 2011 were remediating them. However, based on the evidence provided Dr Lane was unable to confirm that all doors were remediated as necessary. There was a failure of the project management at KCTMO to make their Health & Safety department aware of these issues. Ms Acosta of the project management team became aware that some replacement flat entrance doors failed to self-close fully but dealt with Manse Masterdor to attempt to remediate these issues and did not inform Mrs Wray in Health & Safety, or indeed anyone else within KCTMO, at the project progress meetings.

Ultimately, it was the Neighbourhood team that informed Mrs Wray about the issue, and only this issue, of excessive force required to open the doors. The Neighbourhood team were aware that Manse Masterdor were removing self-closers as a temporary solution but Dr Lane saw no evidence that Mrs Wray the health & safety manager was informed about this.

Regardless of why these faults occurred, the fact that self-closing devices were faulty should have become a significant maintenance issue for the KCTMO. Instead, there is evidence of multiple failures in KCTMO’s system of fire risk management as follows:

  • There appears to be no evidence that Mr Stokes nor any employee of KCTMO ever investigated the Manse Masterdor fire doors to check that the doors had been repaired as necessary.
  • The KCTMO’s system of routine inspections of fire doors consisted only of visual inspections on an ad hoc basis from the common lobby and so the door self-closing performance was not included in what should have been a monitoring process as part of the KCTMO’s fire risk management system.
  • Most significantly, the defective performance of the self-closers was impacting residents and resulting in the caretaker removing self-closing devices from some flat entrance doors at Grenfell Tower.

This was an inappropriate response as self-closers are life safety equipment and should not be removed. It demonstrates a lack of suitable training at KCTMO. By December 2015 Mrs Wray was aware that self-closers were being removed and acted by requesting that the caretaker refrains from removing self-closers. Mr Stokes was aware of this but made no reference to it in his fire risk assessment report of April 2016.

Overall, Dr Lane concludes that flat entrance doors were not maintained in an efficient state, in efficient working order and in good repair. Hence, the arrangements made by KCTMO were not compliant with Article 17 of the Regulatory Reform (Fire Safety) Order 2005. This was despite the KCTMO Fire Safety Strategy 2013 making the statement that fire door repairs were a “priority”. Mr Stokes did not attempt, Dr Lane says, to confirm if the door self-closer issue had been resolved before finalising his assessment of the risk level for Grenfell Tower.

This meant that because of the process KCTMO applied to their fire risk assessments, that any defects or performance concerns with general fire precautions, including fire doors, were not reported into their Action Tracker process. KCTMO relied entirely on this Action Tracker process for closing out fire safety issues when they arose in their portfolio of buildings, except if raised through a complaint or other form of the reactive maintenance process.

Dr Lane’s conclusion is that there was a failure of KCTMO’s fire risk assessment arrangements because the fire risk assessor did not record failures known to him and because a methodical form of risk assessment, inspection and record of the fire doors was not carried out either by Mr Stokes or other KCTMO staff.

These systemic defect problems with the replacement door programme were, therefore, never reported by Mrs Wray and never dealt with by the KCTMO through their monitoring committee. The issues that arose with the fire door self-closers exposed multiple inadequacies with the arrangements put in place by the KCTMO.

Finally, two other significant tests of KCTMO’s fire risk management system relevant to fire doors

According to Dr Lane, these were:

  • The discovery by Mrs Wray that the repairs company, Repairs Direct, had instructed works to the fire doors in the stair at Grenfell Tower without coordinating with the KCTMO Health & Safety team.
  • The issue of fire doors at Adair Tower which were found by LFEPA in October 2015 to not provide the fire protection standard or self-closing devices.

After a fire at Adair Tower, LFEPA issued an enforcement notice for Adair Tower in December 2015. The evidence shows that KCTMO did not understand and did not accept that planned maintenance and routine inspections of fire doors was a requirement of them. Yet the routine inspection and maintenance of self-closers had remained a significant duty required by their own fire risk management system.

By the night of the fire at Grenfell Tower, KCTMO’s main consideration regarding fire door self-closers was a five-year installation programme but they would not be instigating a dedicated programme of routine inspection / planned maintenance for self-closing devices. Dr Lane says, she does not know if Ms Johnson (Director of Housing RBKC) sought competent advice regarding this approach or if it was a technical view held by her independently. However, it was on this basis that KCTMO’s original programme for a three-year self-closer installation programme should be extended to five years and that KCTMO would not instigate a dedicated planned maintenance or routine inspections programme for self-closing devices to fire doors.

The above is a summary of the significant findings of Dr Lane, taken from her Module 3 report.

I appreciate this blog article makes for dry reading, after all the content is taken from a report to the Grenfell Inquiry and a result of 72 deaths on the night of 14th June 2017.

What must be hoped is that all housing providers have already reviewed or will now review their individual fire safety arrangements in compliance, as a minimum, with fire safety law, and that they will continue to do so in the future.