The door to Flat 136
In the final summary piece of our journey through the Grenfell Tower Inquiry, let's consider the story of one fire door on the 16th floor.
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The rapid, mass failure of fire doors at Grenfell Tower was a critical reason for the blaze seeing a much higher casualty rate than other cladding fires around the world.
But while the story of the cladding is now (relatively) well known, the story of the doors is not.
So - in this final piece in my series on the Grenfell Tower Inquiry report findings - I will set out what we now know about why this happened, through the prism of one door in particular: the door to Flat 136.
‘Responsibility for that omission lies squarely with the TMO’
Most of the flat entrance doors in Grenfell Tower - including the door to Flat 136 on the 16th floor - were relatively new. They had been installed during a comprehensive door replacement programme, which took place across all of the blocks of flats owned by the Royal Borough of Kensington and Chelsea (RBKC) in 2011 and 2012.
These doors were composite models: a glass-reinforced-plastic shell with foam insulation inside it. They were supplied by a company called Manse Masterdor which had won the job through a procurement framework used by London social landlords.
The law required these doors to have 30 minutes fire resistance, and to meet British standards for preventing of smoke leakage.
But the doors sold for use across RBKC’s flats were inadequate. First, the testing for fire resistance had not been thorough enough to properly meet requirements. Second, the doors had not passed any smoke leakage testing at all, and were not even advertised as meeting this standard.
This was a simple error on the part of the Kensington and Chelsea Tenant Management Organisation (the TMO, which managed the council homes for RBKC). It had not ordered smoke tested doors, despite the law requiring it.
“Responsibility for that omission lies squarely with the TMO, which should have taken effective steps to make sure that it was procuring entrance doors that met the required standards,” the inquiry report said.
Not only had inadequate doors been procured, but the ones that were delivered were in fact even worse than those tested. The doorsets actually supplied by Manse Masterdor were different from those tested - due to elements such as peepholes, letter boxes, glazing and numbers.
These may sound like minor differences, but they can substantially change a fire performance. Indeed, when undamaged doors were ultimately tested by the Metropolitan Police after the fire, they failed in 15 minutes, not the 30 they had been advertised as possessing.
So even if the doors had functioned perfectly, they would have been well below the necessary minimum standards.
But there was a bigger problem. Even a defective fire door will do some good in a fire if it is closed. Equally, a perfect fire door will be useless if it’s open. And the doors which were being installed around Kensington in 2011 and 2012 had a major flaw in this regard.
‘It is clear that from the outset inadequate screws and fixings presented a systemic problem in relation to self-closing devices’
Fire doors are fitted with self-closing devices, because in an emergency people do not stop to close the door behind them. They simply escape to safety. So a self-closing device is an essential part of a functioning fire door.
Problems with the self-closing devices in the doors installed in RBKC blocks started to emerge quickly after Manse Masterdor began installing them in 2011. The doors had concealed self-closing mechanisms, known as ‘perko’ devices, which look like a small bike chain, and sit within the doorset to pull it closed.
The trouble was, the devices use in the doors being installed in Grenfell Tower and elsewhere around Kensington had a mechanical fault. They regularly got stuck or required too much force to open or close. Complaints quickly started to emerge from residents who found them unusable.
On 17 May 2011, Andy Webster, a project manager for Manse Masterdor, sent an email to colleagues about the entrance doors being installed for the TMO which referred to this defect in the self-closing devices.
“He recognised that the doors should not have left the factory in that state,” the report said. But Manse did not tell the TMO about the problem, and carried on installing them anyway - with the defect.
On 21 July 2011, Carl Stokes, the fire risk assessor engaged by the TMO, emailed Abigail Acosta, who was managing the fire door replacement programme, to tell her that three self-closing devices had been dislodged from the new doors in Grenfell Tower. He suggested that the screws securing the closer inside the door were too short.
Ms Acosta went to Mr Webster, the project manager at Manse Masterdor, about this. He acknowledged that there was a problem with the length of the screws.
“It is clear that from the outset inadequate screws and fixings presented a systemic problem in relation to self-closing devices on the new entrance doors throughout the TMO stock, as the TMO knew,” the report said.
At this point, the problem should have been fixed: the installation programme was still underway, and while it might have felt inconvenient to go back to the start and fix the broken self-closers, it should have been done. The doors being installed across the borough were defective - and both the TMO and Manse Maserdor knew it. There is some evidence of ad hoc efforts to fix some, but nothing was done across the board.
“At Grenfell Tower, the vast majority of the new entrance doors had been installed by the end of June 2011,” the report said. “There is… no evidence that Manse Masterdor replaced the fixings of the self-closing devices on any of the new entrance doors [in Grenfell Tower].”
But the TMO seems to have simply assumed it had. Ms Acosta “appears to have assumed that Manse Masterdor carried out any necessary remedial work and that the problem had been resolved”. Mr Stokes also “assumed the problem had been cured” but “did not carry out any checks” to make sure. Instead, it was neglected.
As the years went by, the inherent problem with the doors caused problems in Grenfell Tower. Doors would get stuck in the open position, or become too difficult for vulnerable residents to use. Various contractors would attend and fix the problem - mostly by simply removing the self-closing device from the doorset completely.
Seamus Dunlea, a handyman who carried out maintenance across the estate where Grenfell was located, was regularly called by residents who had problems with the doors. He recognised quickly that the problem was the self-closer.
“[The mechanisms] had tiny little screws holding them in and they had a massive fat spring inside,” he wrote in his witness statement. “I can't re-attach it because of the fixings, so I would have no alternative but to remove it. I think I did this to about ten doors… This now made that an illegal door, because with the closer pulled out, the door wouldn't self- shut.”
He said he took one of the closers he disconnected to the TMO’s head office to show his seniors the problem. “I got no response from management, after I showed them the door closers that [I] had removed, not a thing, it was basically, [you] sort it out,” he wrote.
Mr Dunlea was told to stop removing the door closers, but nothing was done to ensure the ones he and others had removed were reconnected. Which brings us to Flat 136.
“That was how they treated me, just to lie to me and make out that I was a vexatious complainer.”
By summer 2015, the refurbishment of Grenfell Tower was well underway. Workers for Rydon, the contractor, needed to get access to residents’ flats to carry out work.
In Flat 136, a resident moved out and the flat was left empty for a few days before the next tenant moved in. Rydon carried out work to the vacant flat on 14 August 2015. But when the workmen left the flat, they left the front door open.
Eddie Daffarn, a resident who lived on the same floor, noticed that the door was open after they had left. Worried about the flat being squatted, he tried to pull it closed. But he couldn’t. The door was jammed.
“[I] tried pulling the door the handle [but] I couldn’t pull the door closed. The blockage must have been coming from where the Perko was,” he later told the inquiry.
The door was left open over the weekend, and Mr Daffarn complained to the TMO - saying that someone needed to come and fix the door.
But his complaint was brusquely dismissed. An internal TMO document summarises his complaint: “Front door to a flat was left open following Rydon's working in the property and the door [self-closer] was broken.”
A response is listed from Peter Maddison, a director at the TMO. “I have investigated this matter and Rydon acknowledge that they left the door open in error and apologise for this mistake. The door was in working order and was able to be closed by pulling it shut.”
Mr Daffarn is adamant that this was a lie. He pursued the complaint further, insisting that the door was broken and that it demonstrated a widespread problem with the door closers which Mr Maddison was ignoring.
“That was how they treated me,” Mr Daffarn said to the inquiry, when asked about this episode. “Just to lie to me and make out that I was a vexatious complainer.”
Mr Maddison, for his part, denies lying.
But oddly, in his witness statement to the inquiry, he contradicted his response to the original complaint.
Rather than saying that the door could be pulled closed, in his statement he said: “The door closer was repaired and an apology was given.”
Mr Maddison told the inquiry this was “a mistake in his witness statement”, and blamed his solicitors for “drafting it wrong”.
But something fundamental was not in dispute: the door was standing open when Rydon left. That meant it didn’t self-close. And that should have set some alarm bells ringing about safety.
In fact Eddie was one of dozens of residents to complain about the problems with doors over the years. But nothing was done - beyond the dangerous quick fix of removing self-closers and leaving the doors as non-compliant.
It would take a fire to show the folly of this approach. But it would not be the fire at Grenfell Tower.
‘She took an uncompromisingly negative line without having taken any advice about the consequences for the safety of residents’
The problem with self-closers came to the attention of the London Fire Brigade (LFB) in September 2015 - just a couple of weeks after Mr Daffarn’s complaint.
The LFB’s fire safety team had inspected Adair Tower, a block near Grenfell, and discovered a missing self-closer on Flat 41. It also discovered that Mr Stokes’ risk assessment of the building had identified a widespread absence of self-closers in the building, but had not branded it a concern.
This was a worry to the LFB, which knew the importance of self-closing devices. As a result, it served a deficiency notice on Adair Tower on 12 October 2015, which required the issue be fixed.
Just nineteen days later, on 31 October, Adair Tower suffered a serious fire. Due to the absence of self-closers, smoke got into communal areas and the blaze came very close to causing loss of life, with 50 residents requiring rescue by firefighters.
After the fire, Janice Wray, head of health and safety at KCTMO told chief executive Robert Black about the deficiency notice. But when Mr Black briefed the organisation’s board about the incident, he declined to mention it. “We can only conclude that his failure to do so was deliberate,” the report said.
A few days later, Mr Black also briefed the council’s scrutiny committee about the fire at Adair Tower. He told them that “the fire doors had worked well” and once more said nothing about the deficiency notice from the LFB.
“Robert Black’s failure to report those matters to the committee was a serious dereliction of duty on his part, but entirely consistent with the pattern of concealment he had established in relation to fire safety matters,” the report said.
Eventually, on 23 December, the LFB served an enforcement notice on KCTMO requiring it to remedy the issue with the self-closers, and sent a further one on 18 January 2016 relating to the sister block, Hazlewood Tower, which had the same issue.
After these enforcement notices, the LFB’s team held meetings with Ms Wray and her colleagues in which they emphasised the need for regular checks on self-closers. They explained that the TMO had a legal duty to make sure functioning self-closers were in place across all of its blocks, and that a system of regular checking and maintenance was set up to ensure this remained true. “That was, we consider, a clear and unambiguous warning to the TMO,” the report said.
But action was not taken. Ms Wray emailed other London housing providers to ask if they had a policy for regularly checking door closers. Most responded to say they did not. The matter was then discussed at KCTMO board meetings, and a report was sent to RBKC.
The LFB, though, were still investigating other blocks. After a review of Grenfell Tower, they served a further deficiency notice, in November 2016, raising concern about missing self-closing devices on the two doors their team had inspected. The notice said the issue should be fixed by May 2017.
Meanwhile, RBKC received KCTMO’s report into the fire safety strategy in February 2017. Drafted by Ms Wray, it set out the LFB’s requirements in relation to the installation and inspection of self-closing devices. It also estimated that 50% of the flat entrance doors had missing or broken devices. This should have been seen as a very serious safety issue.
But the focus instead was on money. Laura Johnson, director of housing, responded by saying she wanted to spread the work to fix the self-closers out over five years rather than one in order to “make funding more manageable”. On the question of regular inspection “she took an uncompromisingly negative line”, rejecting the proposal as a “continuous burden” on funding and one which she “did not think was necessary”.
“She did so without having taken any advice about the consequences for the safety of residents,” the report said. An internal email she sent, revealed during the inquiry, tersely described the matter as a “non-issue”.
Inside Grenfell Tower, the broken self-closing devices remained unfixed. Of 120 flats in the tower (excluding seven added to the lower floors during the refurbishment), 77 had broken or missing self-closers. This included Flat 136.
The night of the fire
At close to 1am on 14 June 2017, fire spread out of the kitchen window in Flat 16 on the fourth floor of Grenfell Tower, ignited the cladding and climbed the outside of the building.
Within minutes, it had broken into the kitchen above, in Flat 26, and started a ferocious and immediate fire. The residents fled. Minutes later, the same thing happened in Flat 36.
And so on and so on, all the way up the tower between 1am and 1.30am, 20 fires started in 20 kitchens in the flats ending with the number ‘6’. The fires were immediate and fierce: breaking in through windows and engulfing the kitchens in a matter of seconds. Residents fled immediately.
This is why self-closing devices are so important. If a fierce fire breaks out suddenly, your body will revert to fight-or-flight mode. Your brain - evolved as it is to keep you alive in moments of danger - will disconnect from all thoughts other than those which involve escape and survival. This means people do not stop to close doors behind them. That isn’t their fault, it’s a consequence of tens of millions of years of evolution.
And so as the residents fled, their front doors stood open behind them. And all the smoke from the burning cladding, all of the toxic fumes including cyanide from the burning insulation and all of the additional smoke from the rapidly developing furniture fires inside their flats rolled out unhindered onto the landings.
As a result, when the other residents of the tower opened their front doors, they were confronted with an impenetrable wall of irritant, choking black smoke. Many - particularly those with health issues or children - closed the door immediately and phoned 999 instead of leaving. They were told to stay put and await rescue which - in most cases - would never come.
The fire reached floor 16 outside Flat 136 by 01.24. The resident of Flat 136 fled rapidly when the fire broke into his kitchen. He found a lobby clear of smoke, went down the stairs and out of the building. “He left his front door open and, since it did not have an effective self-closing device, smoke entered the lobby,” the report said. “Thereafter, conditions on that floor deteriorated rapidly.”
Mr Daffarn left his flat shortly afterwards, having been alerted by his neighbour’s smoke alarm. He opened his front door. “As I opened my door a gush of thick, swirling acrid smoke came rushing in to my flat,” he recalled in his witness statement “It wasn't a small amount of smoke either, but loads of smoke.”
He slammed the door closed. After receiving a phone call from a friend outside, he realised he had to escape. He put a wet towel round his mouth, and went out into the landing. But it was pitch black and he couldn’t find the exit stair.
“I started to inhale the smoke. I thought to myself ‘shit man, this isn't going to end well for me’,” he recalled.
He dropped to the floor. There, the smoke was thinner, and he saw a firefighter lying on the ground who pointed the way to the stairs. Eddie made it out.
But two other residents on the 16th floor, Joseph Daniels and Sheila, did not.
Giving general evidence into the cause of the 72 deaths at Grenfell, toxicologist Dr David Purser, called the rapid spread of smoke to lobbies “a key event”.
“I feel [this] strongly inhibited those who had remained in their flats from attempting to escape,” said Professor Purser. “[It] led to many of them remaining in their flats and ultimately led to them being overcome by asphyxiant gases and dying in their flats.”
The position today
What conclusions can we take from this saga? The story engages many of the key themes from the rest of the Grenfell Tower Inquiry report conclusions we have covered: a failure to take safety seriously enough, procuring based on price, poor quality products and inadequate testing.
But this particular story also cuts very deeply to the heart of another aspect of the Grenfell tragedy - the way social housing residents’ complaints are ignored, and the way the safety and maintenance of their homes was treated as an unnecessary annoyance and one where cost should be kept to a minimum - not a legal duty to paying customers.
It is ironic, bitterly so, that RBKC was able to find money for a cosmetic overcladding of the tower with little demonstrable benefit to residents, but could not put up the cash for a basic but unflashy programme of fixing fire doors. The former, of course. came with a photoshoot and a press release at its conclusion, and was visible to wealthier residents of the borough. The latter didn’t and wasn’t.
Questions should also be asked of Manse Masterdor - a company which was defunct by the time of the fire, but whose former directors could have been called to give oral evidence and weren’t. Like the cladding manufacturer, they sold a product which was flawed, didn’t meet standards and didn’t match the testing for which it had been advertised.
It is also worth reflecting on the position today. The first phase of the inquiry recommended quarterly checks on fire door self-closers. This eventually became annual when the government implemented it, but is now in place. That at least means all self-closers in higher risk buildings will have a regular system of checks - providing the landlord complies with the law.
Any who feel it is an unnecessary burden should consider why it is being imposed. Any who feel that it is an over-the-top response to the specific set of circumstances present in a single incident should consider the 2022 Bronx apartment fire, where there was no combustible cladding at all, but there was a mass failure of door closers. That fire killed 17 people, including eight children, which makes it more deadly than any residential cladding fire except Grenfell. Fire door self-closers matter a great deal.
Fire door manufacture itself is in a less certain state. Initially, composite doors were taken off the market entirely as many failed similar tests to those at Grenfell. But this ban was lifted, with little change put in place to prevent a repeat.
Talking to people in the industry, I understand that door designs have changed. Many composite doors now have a solid timber core rather than plastic insulation.
But the problem of doorsets being tested in the most favourable way possible, and then leaving the factory in a far different configuration persists.
Thanks for reading
This piece brings to an end my piecemeal reports on the inquiry. You can find them all on the list below. Older ones will now be behind a paywall, but if anyone wants access and can’t afford to pay, hit reply and I will see what I can do.
I will leave with the reflection that despite all the wrongdoing set out in so much forensic detail in the inquiry report, we are yet to see anyone meaningfully held to account. We have had truth - to a point. We have not yet had justice.
RBKC and the TMO as client and building control
The recommendations and the government’s response to them
This content is not behind a paywall, but since it takes time to create and upload each piece, do please consider becoming a paid subscriber (especially if this project is something that you value, and you have the means to do so), which is either billed monthly at £3.50 or annually at £35. A paid subscriber has full access to the back catalogue of posts.
If you pay £40 or more for an annual subscription, I will send you a signed copy of my book. Or you can buy a copy here.