The Grenfell Inquiry has been a six-year affair investigating the 2017 fire at Grenfell Tower. It found several failures within the private sector and Government that led to the death of 72 people. The aluminium composite material (ACM) cladding was quickly identified to be the “principal" reason for the spread of the fire.
Sir Martin Moore-Bick, a retired High Court judge, has published the final report.
Knowsley Heights warnings ignored
In 1992, the 11-storey Knowsley Heights tower in Huyton, Merseyside, caught fire. This prompted a warning from experts about ACM cladding and its ability to catch alight. Following that incident, another occurred at Garnock Court in Irvine, North Ayrshire, and concerns were repeated.
Moore-Bick explained that though it had been noted as dangerous, the cladding wasn’t banned as it had already been classed as meeting a British safety standard.
Lakanal House inaction
Large-scale safety tests were conducted in 2001 involving aluminium composite panels and unmodified polyethylene cores, which were described as having “burned violently”. However, the results remained confidential and the Government made no moves to change any rules with regards to the cladding.
In 2009, a fire at Lakanal House in Southwark, London, killed six people. Following the blaze, the coroner recommended a review of building regulations should take place. This was “not treated with any sense of urgency”. Concerns about the fire risks of cladding after this were met with a “defensive and dismissive attitude” by officials and some ministers.
The following year the coalition Government embarked on a deregulation drive and this reportedly dominated the Government’s thinking “that even matters affecting the safety of life were ignored, delayed or disregarded”. During that period, the Government “determinedly resisted” calls from across the fire sector to regulate fire risk assessors and to amend the Fire Safety Order. The latter would have made it clear that it applied to the exterior walls of buildings containing more than one set of domestic premises. While the Government did commission a review relating to the evacuation of vulnerable people, it failed to consult those who represented their interests.
Privatisation of Building Research Establishment
Originally known as the Fire Research Station, the Building Research Establishment (BRE) is a Government body which carries out research into and testing of construction methods and products. It became privatised in 1997 and the department limited the scope of advice it was asked to provide on fire safety matters.
As a result, the department managed to deprive itself of the full benefit of BRE’s advice and experience. The report added: “On occasions it deliberately curtailed investigations before any proper conclusion had been reached.”
BRE was recognised nationally and internationally as a leader in fire safety, but from 1991 much of the work it carried out in relation to testing the fire safety of external walls was “marred by unprofessional conduct, inadequate practices, a lack of effective oversight, poor reporting and a lack of scientific rigour”.
Systematic dishonesty
One of the reasons Grenfell Tower was clad in combustible materials was down to "systematic dishonesty" on the part of those who made and sold the rain-screen cladding panels and insulation products. There were several strategies to manipulate the testing processes, misrepresent test data and mislead the market. The BRE was "complicit" and its systems "not robust enough to ensure complete independence and the necessary degree of technical rigour at all times" with regard to the insulation product used on Grenfell Tower, Celotex RS5000.
Arconic Architectural Products manufactured and sold the Reynobond 55 PE rain-screenpanels used in the external wall of Grenfell Tower. According to the findings, it "deliberately concealed from the market the true extent of the danger" of using this product in cassette form, particularly on high-rise buildings. It caused the British Board of Agrément (BBA) to make statements in the certificate that Arconic knew to be "false and misleading".
Celotex manufactured RS5000, a combustible polyisocyanurate foam insulation, and in an attempt to break into the market for insulation suitable for high-rise buildings, it embarked on a "dishonest scheme to mislead" its customers and the broader market.
Troubled relationship
Grenfell Tower's refurbishment was managed poorly by the Tenant Management Organisation (TMO), according to the inquiry. Before the refurbishment, the relationship between the TMO and its residents was described as being "troubled for many years."
Two independent reports in 2009 had drawn attention to numerous serious flaws in that relationship. The second of those reports identified governance, customer service, staff attitudes and a poor repairs service as constant themes of the investigation. It also found that the residents’ lack of trust in the TMO lay at the heart of the problems. The reports made 34 recommendations for change. But despite these concerns, eight years later the TMO had shown little sign of any change and appeared to have learnt nothing about how to treat, or relate to, its residents.
The findings concluded that relations between the TMO and many of Grenfell Tower's residents were characterised by "distrust, dislike, personal antagonism, and anger." The TMO lost sight of the fact that its residents depended upon it, and that this created an unequal relationship.
Lack of preparation
The London Fire Brigade (LFB) was found to have been ill-prepared. The Lakanal House fire should have alerted the LFB to the shortcomings in its ability to fight fires in high-rise buildings, according to the Inquiry. In the years immediately preceding the Grenfell Tower fire, senior managers at the LFB failed to take steps to ensure that its arrangements for handling fire survival calls reflected national guidance.
Those failures were attributable to a “chronic lack of effective management and leadership”, alongside an “undue emphasis on process”, said the inquiry. There was a tendency to treat problems that managers became aware of as undeserving of change or too difficult to resolve, even when they were concerned with operational or public safety.
The result
All of these failings over the course of decades led to a disaster in building safety management. The report identifies numerous contributing factors, including the use of combustible cladding materials, inadequate regulations, and the London Fire Brigade's lack of preparedness.
The Inquiry highlights a culture of complacency and disregard for safety within the construction industry. The Grenfell Tower disaster serves as a stark reminder of the consequences of negligence and a failure to prioritise safety and underscores the need for significant reforms to building regulations, fire safety standards, and industry practices to prevent similar tragedies in the future.
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