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It will go down as one of the most high profile Health & Safety cases in modern UK history, but the tragedy that unfolded at Grenfell Tower isn’t just a story about building regulations or protocol failures, it’s a powerful story about people, as the BBCs Tom Symonds reports.

A catalogue of safety problems allowing the Grenfell Tower fire to take hold have been indentified in reports from five experts for the blaze inquiry.

Dr Barbara Lane says a “non-compliance” culture had existed with basic fire measures missing or “inadequate”.

She listed issues with ventilation systems, lifts, fire mains and doors.

The reports suggested cladding was incorrectly installed, and the primary cause of the “catastrophic” spread of June’s fire, which caused 72 deaths.

The hearing was played the audio of the first 999 call made on the night, by the tenant of flat 16 on the fourth floor – where the fire started – Behailu Kebede, who survived.

In it he told the operator: “Quick, quick, quick. It’s burning.”

A montage of video sent in by the public of fire, showing burning debris falling from the tower was also shown. “Oh my god,” says one woman , while another could be heard crying as the fire became out of control.

The inquiry also heard the fire service advice to residents to “stay put” in their flats had “effectively failed” within around half an hour of the blaze starting.

The reports have been published at the start of the fact-finding stage of the public inquiry.

Dr Lane said: “The building envelope itself was therefore a major hazard on the night of the fire.

“The active and passive fire protection measures within Grenfell Tower were required to mitigate an extraordinary event. As a result, the consequences were catastrophic.”

The experts’ reports highlighted:

  • Most of the fire doors at the entrance to the 120 flats had been replaced in 2011 but neither they or the original doors still left in place complied with fire test evidence
  • The lifts failed to perform effectively, hindering the transportation of firefighting equipment and creating an “unnecessary risk” to residents who could not use it to escape
  • The stairwell, the only escape route in the tower, became clogged with smoke and then hit by fire
  • The fire service had to pump its own water into Grenfell Tower – the building’s “dry fire main” system was “non-compliant” with guidance at the time of construction and was “non-compliant with current standards”
  • The smoke control system did not operate correctly, reducing the ability to improve both escape and firefighting conditions
  • A lack of regulations requiring a central alarm system in residential buildings such as Grenfell Tower
  • Existing building guidelines and tests allow “obvious dangers” to be incorporated into cladding systems routinely
  • An “architecture crown” fitting at the top of the tower caught alight and fell down, allowing the fire to move around the tower not just up

When the fire was first reported at 00:54 BST, residents were initially given the advice to “stay put” inside the building.

In her report, Dr Lane said this advice had “effectively failed” by 01:26.

A change in policy recommending residents try to leave was not made until 02:47 BST, one hour and 53 minutes after the first emergency call.

Prof Jose Torero’s report said a “stay put” strategy was appropriate while the fire was only in flat 16, but not once the fire started to spread up the building.

He said that after the fire had breached the flat – the “second phase” – it would have been better for residents to have left their flats and exited the building.

The inquiry continues.