Lakanal House fatal fire: the price of failure

1 May 2013

The inquest into the fatal fire at Lakanal House says a failure to involve building control and adhere to fire guidelines during refurbishment work was a contributory factor. Elaine Knutt reports.

Photograph: Press Association

At the 12-week Lakanal House inquest, the emails, minutes and memoranda of the Decent Homes refurbishment that upgraded the south London 1960 block two years before the fatal fire in July 2009 were laid bare.

Counsel for the six victims’ relatives questioned witnesses from Southwark Council, its contractor Apollo, subcontractors and suppliers to establish the lines of responsibility that led to the building being substantially weakened in terms of fire resistance, and a critical opportunity lost to pick up breaches in fire compartmentation from earlier work.

In the final narrative verdicts, the failings of the refurbishment became just one of several factors. The verdicts criticised the London Fire Brigade’s (LFB) “stay put” advice to the six trapped residents — advice that might not have been made if the local LFB watch had, as is required, familiarised itself with the design of local high-rises.

And the council was criticised for failing to commission a fire risk assessment of the building two years after it acquired the statutory duty to do so under the Fire Safety Order 2005, which lays responsibility for ensuring safe means of escape on the building’s owners.

Incorrect rating

But from the industry’s point of view, the inquest uncovered alarming evidence. The key issue was the installation of spandrel panels in the replacement window assemblies that were not rated Class 0 for surface spread of fire, as required by Part B of the Building Regulations. (Table 40 requires that all materials installed on buildings above a height of 18m must be Class 0.) The panels were able to ignite, burn through in less than five minutes and then introduce a flame source into Flat 79 an estimated 15 minutes after a television in Flat 65 caught fire.

The expert analysis of the fire came from Dr David Crowder of BRE Global, which has a contract with the Department for Communities and Local Government (DCLG) to investigate serious fires. Crowder later told CM: “Had a Class 0 panel been installed, I wouldn’t have expected that panel to have sustained flaming and allow the flame to pass through. If the recommendations in Approved Document B had been followed, this wouldn’t have happened.”

But as counsel for the relatives explored during days of cross-questioning, neither the client nor contractors submitted a Building Control notice of any sort, or sought advice or consultation on Building Regulations. In fact, Building Regulations or fire protection of any kind barely featured in their discussions, except in relation to options on fire-rated kitchen doors. Failure to trigger building control involvement meant there was no inspection of the works or building control presence on site that might have spotted the historical problems.

These included a weakness in fire compartmentalisation dating from the installation of central heating in the 1980s – when the fireproof ceiling in the common parts was breached – and problems with the cross-ventilation strategy. Also, a section of the flats’ internal timber staircase juts out into the corridor, and the inquest heard that this had been inadequately fire protected in the 1980s, leaving a direct route for fire to travel from flats to the corridor.

The failings in respect of surface spread of flame and Class 0 were clear, but the jury heard conflicting evidence about how Part B should be interpreted on the fire resistance of the panels. The transcript reveals how even the coroner and barristers struggled to follow the trail from the Building Regulations to Approved Document B to supporting guidance. One expert’s view was that the Lakanal panels should have had a one hour fire-rating, only for this to be contradicted when Brian Martin of DCLG gave evidence that there was no such requirement.

Conflicting evidence

Crowder explains: “If you decide to have a fire-resistant facade, then you need fire-resistant glazing and then they have to be fixed shut to prevent residents from opening them. Instead, you have the Class 0 requirement on fire spread to create a sufficient time delay [for the fire brigade to deploy], typically no more than 30 minutes.”

In the event, coroner Frances Kirkham presumably agreed that the issue at Lakanal was not a failure of the Building Regulations, but a failure to pay attention to them. In a series of “Rule 43” letters to communities secretary Eric Pickles, to Southwark Council and others, she did not press for any amendments to the Building Regulations, but did put the case for clearer guidance on Approved Document B; better training for staff involved in construction and refurbishment projects; the preparation of “fire plans” in high-rise buildings to guide any future contractors and surveyors; and recommended retrofitting sprinklers to high-rise blocks – a measure previously deemed impractical on cost grounds (see below).

The principles of fire protecting the external facade of a high-rise block are set out in Building Report 135, additional guidance to Part B produced by the BRE. Rather than attempting to make the entire facade fire resistant, the guidance accepts that flames will spread from level to level when the glazing fails. The aim is therefore to delay this process through the correct specification of materials, rather than prevent it. In the diagram below, the cladding option on the right does not contribute to the spread of the fire. Image copyright IHS 2013, reproduced by permission

Disasters waiting to happen?

But are there other projects out there showing a similar disregard for fire safety? On the project team’s failure to involve Building Control, Kevin Dawson MCIOB, head of building control at Peterborough City Council, says: “It does happen, but fortunately rarely. With refurbishment, it all hinges on definition – a pure refurbishment that involves like-for-like replacement may not involve Building Control, but as soon as you upgrade, you need to formally make an application.” In fact, the Lakanal project began as “term maintenance”, only securing Decent Homes funding – and moving into the realm of “material alteration” – later on.

Paul Everall, chief executive of Local Authority Building Control, also acknowledges there can be blind spots. “People who don’t know the detail of Building Regulations often envisage it as applying to new builds, while increasingly refurbishments are done under Competent Person schemes,” he says. Again, the Lakanal transcripts showed there was a mistaken belief within the team that the panels were covered by the FENSA glazing Competent Person Scheme.

Geoff Wilkinson MCIOB, vice chair of the building control and standards faculty at the CIOB, agrees on the need for clarity: “The issue is making it clear that what appear to be relatively minor works [should be] brought under Building Control. A Decent Homes upgrade or installing cable TV can all end up with holes going into the fire protection. So even if it seems small, it should be supervised by building control.”

Everall also questions why Southwark’s building control team apparently failed to spot a 14-month refurbishment project on a high-rise building. But even if they had done so, the enforcement options available to them would have been limited. However, new powers for building control departments and approved inspectors to issue stop notices, and extend the period under which they can bring enforcement action over breaches, are under consultation. 

As for the project team’s apparent lack of awareness of fire protection and compartmentation, many fear that fire safety is often the last priority in a project list headed by energy efficiency. Mike Wood, a spokesman for the Fire Sector Federation, which brings together the fire service and fire protection industries, says: “Fire safety doesn’t receive the level of attention it properly deserves. But there’s a duty of care on professionals to seek guidance, especially on material alterations.”

Wood highlights problems in both refurbishment and new-build. “People design out fire protection – you see fire-resistant glass being replaced by safety glass – on unwarranted assumptions about the likelihood of fire.”

In respect of fire compartmentation problems, Lakanal is not unique. Marie Curie House (see box, page 32) is on the same Camberwell estate and is identical in design to Lakanal. The 2009 photos show similar problems with the corridor ceiling and staircase section, as well as holes in duct walls from a retrofitted entry system.

The photographs were taken a week after the Lakanal fire by surveyor and fire safety expert Arnold Tarling, from south-east London practice Hindwoods, who has extensive experience in London’s high-rise blocks. “I’ve seen this happening not just in Southwark, but all over London. People think that they’re compliant with Part B; but there are an awful lot of people out there who are just not well versed enough in what they’re doing.”

In his view, this applies to inspectors as well as installers: he claims to know of three blocks in Lambeth where the council’s contractor retrofitted a concierge system, knocking a hole in the fire compartmentation around a staircase in the common parts. But Building Control signed off the work, and a later fire risk assessment commissioned by the council (under the Fire Safety Order 2005) also failed to pick up the problem. “The risk assessment was done by an experienced ex-fireman who picked up a lot of things, but it’s difficult to pick up everything if you do not follow a logical, detailed route around the building.”

Tarling also points to widely held misconceptions about products and installation. He gives the example of fire-retardant expanding foam, often used to stop holes where pipes and cables enter the structure. “It says four hours on the tin, but that’s if it’s installed between two [fire retardant] surfaces at 5mm wide and 200mm deep. It simply hasn’t been tested around cables or pipes, and the tin doesn’t say you can use it on a timber-frame or around glazing. And if you’re using it 50mm wide and 50mm deep, it’s just not going to work.”

An issue raised by several of the above interviewees is the need for third-party accredited contractors to carry out works such as installing a fire-rated ceiling in residential accommodation: several industry schemes exist, including the BRE-run LPS1531 scheme. However, since this scheme was introduced in 2008, only 30-40 companies have been accredited. “Some are specialists, and some are main contractors. But we estimate there are 700-800 companies out there doing this work at least from time to time,” says Ian Stewart, passive installer scheme manager at BRE Global.

Further action

The inquest is over, but legal action over the six deaths is set to continue. The LFB and Southwark Council have been named in a civil claim for damages under the Human Rights Act brought by the father of victim Dayana Francisquini, and it is understood that pre-action letters in relation to future claims by the other victims have been received by the LFB, Southwark and its refurbishment contractor Apollo.

Solicitor advocate Sophie Khan is bringing the Human Rights Act case, claiming redress for an avoidable death and associated distress and trauma. The details have not yet been lodged, but Khan told CM that the compensation claim against Southwark will be based on its failures under the Fire Order, historic failures on fire compartmentation, and the errors made in the 2006-07 refurbishment. “Public authorities should realise that something went seriously wrong, and people died there. There has to be redress for the families,” she says.

What price a sprinkler?

In her Rule 43 letter to communities secretary Eric Pickles, coroner Frances Kirkham put the case for social landlords to retrofit sprinkler systems into older high-rise blocks. Building Regulations require new build residential accommodation to be fitted with sprinklers as part of the fire protection strategy, but retrofit has always been thought to fall on the wrong side of the cost/disruption/benefit equation.

Following the Lakanal fire, the British Automatic Fire Sprinkler Association ran a test project on Callow Mount, a 13-storey, 1960s tower in Sheffield. The 2011 installation was completed to BS925 in four weeks without decanting residents, at a cost of £1,150 per flat.

BAFSA’s Steve Mills says the difficulties of retrofitting sprinklers have been overstated. “Previous assumptions were based on overall costs of new pipework and tanks, and a separate rising main. But normally in flats you’ve got plenty of pressure anyway, so you’re able to use domestic water risers and there’s no need for extra pipework. In the flats we used cPVC pipework that doesn’t burn, glued together with a non-flammable solvent.” 

Asked about the coroner’s views on sprinklers, BRE Global’s David Crowder was equivocal. “Sprinklers are subject to the same weaknesses as everything else [such as fire detection, compartmentation and fire spread], or they become the factor people rely on to the detriment of other factors.”

But Mills says: ‘Where you’ve got a stay put policy [based on integrity of the fire compartment], you need to be able to control the fire in the early stages, so that you don’t get to flashover point. The pilot has shown it’s economically viable.”

Fire compartmentation: the lessons to be learned

These photographs, taken at Southwark’s Marie Curie House in July 2009 by Arnold Tarling RICS, show breaches in fire protection resulting from earlier refurbishment work that he says are all too common in older high-rise blocks.

Clockwise from left: a corridor with a combustible ceiling and a broken fire break above; inadequate fire protection to the maisonette’s internal staircase jutting into common parts; a duct smashed out to install the door entry system and the cables.

Tarling also highlights similar problems at blocks in Lambeth and elsewhere in London.

If the spandrel panels in the window assemblies had been Class 0 rated — as they should have been — the fire would not have spread so quickly, according to the inquest findings.

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