‘Grenfell Tower; Systematic Failure’ | Written By A Fire Officer Who Was There

Steve Dudeney, a former London Fire Brigade Borough Commander who was on scene at the Grenfell Tower fire tragedy, has spoken of his experiences of that fateful night on the eve of the publication of a report that has criticised the actions of the London Fire Brigade. 

The former senior officer – who has since retired from the Brigade -speaks candidly about his experiences in a blog that has been published on his WordPress site (link at the bottom of the article). 

In the blog, Steve says:

‘The day after the Grenfell Tower Fire, once I had analysed and made sense as best as I could, the unimaginable devastation that I had witnessed on the previous day when I attended the incident, I realised that the consequences for such an awful loss of life and destruction of property were going to be far reaching.

‘At the time, the media were full of praise for the herculean efforts of my colleagues in LFB and the thankless task they faced trying to save lives in a building that was completely alight and with every system designed to prevent fire not only failing but actually making the spread of fire and smoke worse in its unpredictable nature.

‘I have never really thought about where my natural cynicism comes from, maybe an adult life lived in the past few decades working for a public body where soundbites and promises often end up with those on the front line working harder and less efficiently, while the ‘good ideas club’ slap themselves on the back and walk off into the sunset. 

‘Maybe it’s living in a society where at a pretty young age I recognised media headlines were often style over substance and a quirky banner headline, a handful of quotes taken out of context was worth so much more than objective impartial analysis.

‘So, it was in the numbing days after the fire, I realised and made it known that somewhere down the line the LFB would shoulder a lot of the blame for the loss of life on the night. 

‘Within that first week after an appalling misreading of the public mood, those in Government came belatedly spluttering out of the starting blocks promising a public inquiry and that lessons would be learned. 

‘Those in my line of work, who had been around for many years had seen and heard all of this before knowing full well the promised lessons learned from previous disasters were, by and large, now being used as door stops or gathering dust on a shelf.

‘Throughout that summer, my mood darkened as the Grenfell Survivors were not given the scope of the public inquiry that they felt they deserved. 

‘More and more departments, organisations and companies were potentially implicated by cost saving, oversight and blunder, many of which if rumour is to be believed cut a path directly back to people who may sit in lofty positions with the establishment.

‘Finally when the scope of the inquiry was publicised and we found out that unfathomably it was going to look at the ‘Events of the night’ first, before even beginning to look back at everything from deregulation to disentangle business from red tape to the fact that Grenfell Tower was clad in flammable material and fire stopping was as good as non-existent. 

‘At that point, I knew that today…. the day I read the handful of words or sentences taken from a thousand pages of the phase one report and tuned into damning headlines… was coming.

‘Unsurprisingly, the day after the embargoed report is made public, the media have got their hands on it and laid a smooth and well-lit path blaming the Firefighters for the loss of life that night with barely a word about how the building had catastrophically failed within minutes of their arrival.

‘I have said before, so won’t go into great details again how the learned experts who analysed the events of the night second by second with great hindsight in the cold light of day have come to conclusions after hours of detailed analysis that Firefighters on the ground only had seconds to do at an incident that was completely unprecedented in terms of the cladding fire in UK experience but disastrously and uniquely coupled with total failure of the compartmentation and fire stopping. 

‘This fact alone makes the Grenfell Tower fire an event not seen anywhere previously.

‘The report details that the ‘Stay put’ advice should have been abandoned between 01:30 and 01:50. 

‘It is a matter of fact and record that no Senior Commanders from LFB were in attendance at the incident until after this time. 

‘A couple of middle ranking Station Managers had arrived and were immediately swamped with trying to make sense of the multiple fire survival calls they found themselves in the midst of.

‘So, the personnel, through an absolute mist of shock and horror trying to make sense of information that was changing, for the worse, second by second, were the handful of appliance commanders on the scene. 

‘These brave individuals who the organisation expects to command incidents where four Fire engines and around 20 Firefighters are in attendance, were expected to have the clarity in the ‘fog of war’ of a small Military platoon facing a sudden unexpected onslaught from several regiments of the enemy, to recognise that Stay Put had failed and should be reversed.

‘In the midst of that constantly changing environment where every second of change required a minute of thought it was so desperate, I implore anyone to explain to me how you come to that decision. 

‘Again, as discussed previously. Even if by some miracle of divine intervention that decision was made…. at 01:30 to give them the best chance. How was that to be communication to the hundreds of residents still in the tower at that time?

‘There was (for very good reason that I will not go into here) no public fire alarm. 

‘In the noise and confusion would people, especially those who were still blissfully unaware at that time have heard or taken notice of loud hailers. 

‘Evidence from some survivors and tragic testimony from some of those who were trapped clearly demonstrates some people did try to escape and facing choking blinding smoke & fumes either went back, went further up into the building to escape the poisoning atmosphere or got no further than opening their front doors.

‘It is true that a number of people took that brave decision and were able to escape, some barely conscious as they got to safety, others collapsed and resuced by Firefighters on the stairs. 

‘But if the order to evacuate had been communicated and heard, how were the LFB meant to encourage those people to make an orderly escape?

‘Witness testimony from many Firefighters for those who have been bothered to read it, is littered with reports of crews who did reach people in flats on upper floors where they often refused to open doors or found escape untenable and remained in their flats, or most tragically Firefighters, physically exhausted from the climb to those higher floors in heat, smoke & debris quickly realised that to remove people was to condemn them to a certain death within minutes of leaving, at that time, a relatively safe environment, not being able to comprehend the spread of fire that was to follow.

‘I am afraid, for all of the great minds and detailed analysis and investigation into the night of the fire, this seems to have been overlooked. 

‘I admit to having had no sight of the report as yet, but even if the facts I mention above have been included, they have been overlooked in what appears to be conclusions built solely on technical analysis without any consideration of human behaviour, emotions, lack of experience of this type of failure anywhere previously and an understanding of the utter horror those responding, trapped or witnessing had to endure.

‘In summary, I can only conclude with as much objectivity as I can muster having been involved in the incident, that although mistakes were made by LFB, these were not reasonably predictable in terms of the rapid deterioration of events on the night and as such the conclusions of the report have, in my opinion almost been pre-determined to scapegoat the London Fire Brigade and its personnel to what end?

‘Sytsematic Failure. Those are the headlines today in relation to the LFB. 

‘I’d argue that systematic failure has appeared everywhere in the sorry tale of the Grenfell Tower Fire. 

‘From deregulation of Fire Safety laws in the early 2000’s, from the apparent cost cutting and poor oversight of the refurbishment of the Tower, to the way in which the inquiry was set up about face and the conclusions drawn at the end of phase one.’

You can follow Steve Dudeney on twitter at @SteveDude68.

To read Steve’s other blogs, click here


  • Vast appreciation for all the firefighters that night!
    The Tories always protect their friends and stick together. It was a Tory government who deregulated building control for the sake of the big house builders.It is a Tory local authority.
    It was clear to me on the day of the fire by a simple search of the building regs that the refurb of Grenfell did NOT conform to the building regs part B . Forget the illegal cladding for a moment, in a major refurb all CURRENT regs are applicable. Grenfell was built with only one protected escape, and no sprinklers, but current regs say that above 7.5m there must be an second escape or sprinklers. As I understand it this regulation (the law) was not complied with.
    In the case of Ronan Point a similar thing happened, but no so bad…….a collapse caused by failure to conform to building regs was overlooked because it began with a gas explosion. So they blamed a plumber because British Gas did not do the installation so passed the buck. They never proved that any fault created the leak, in fact the lady in the flat could easily have left a gas ring on, unlit all night. But they focussed away from big builders, local authority and Building control to blame a plumber. This led to CORGI being formed.

    • This is NOT correct … ‘Forget the illegal cladding for a moment, in a major refurb all CURRENT regs are applicable. Grenfell was built with only one protected escape, and no sprinklers, but current regs say that above 7.5m there must be an second escape or sprinklers.’

      The refurbishment would have been dealt with under Regulation 4 (3), which effectively states that work upon completion, where it did not comply, is made no more unsatisfactory, it was not a requirement to upgrade the building to meet ALL current standards. It was hoped that Hackitt would address this in her report but it was overlooked.

      The second point is that current guidance (Approved Document B, Vol 1, 2019) only requires a single escape stair in a residential apartment block and sprinklers are only required above 30 meters (consultation currently looking at reducing this to 18 meters). The gudinace for second escape OR sprinklers above 7.5 meters relates to a single house.

  • The fire fighters would have assumed they were attending a fire in a properly constructed building, with compartmented sections which could confine the fire. What they found was a jerry built, oversized stucture, with inadequate escape routes (so that crowds trying to get away would have been crushed together in the stair well). The Tory council’s relaxation of proper building regul;ations so the developers could make a big profit is to blame. The addition of the sub standard cladding, in itself a fire hazard rather than an insulation protection, was, allegedly, at the behest of local private residents who did not like the look of the building without it. Again, the Council’s permission for the firm to use substandard materials was in the interests of profit, not people. Failure to supply correct lists of residents to be rescued cannot have helped.

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