The path to the Grenfell Tower disaster was set in train by ‘decades of failure’ by both the state and the corporate sector.
Inquiry chairman Sir Martin Moore-Bick – across 1,694 damning pages – identified a slew of failures he attributed to serial ‘incompetence’ and ‘dishonesty and greed’ by ‘unscrupulous’ businesses.
Together, this toxic cocktail of malpractice, ignorance and money-driven deception resulted in the tragic deaths of 72 people after a faulty fridge-freezer on the fourth floor of the 24-storey block in Kensington sparked a catastrophic blaze which tore through the building – aided by recently installed flammable cladding.
On Wednesday, more than seven years after the blaze – the most catastrophic residential fire since the Second World War – a root-and-branch public inquiry into what happened finally reached its chilling conclusion.
In the report, Sir Martin wrote: ‘The simple truth is the deaths that occurred were all avoidable and that those who lived in the tower were badly failed over a number of years and in a number of different ways by those who were responsible for ensuring the safety of the building and its occupants.’
The Grenfell Tower fire in West London in June 2017 left 72 people dead in a shocking tragedy
The 72 victims of the Grenfell Tower fire in June 2017 are pictured as follows – (top row left to right) Mohammad Al-Haj Ali, Ya-Haddy Sisi Saye, also known as Khadija Saye, Anthony Disson, Khadija Khalloufi, Mary Mendy, Isaac Paulos, Sheila, Gloria Trevisan, Marco Gottardi, (second row left to right) Berkti Haftom, Ali Yarwar Jafari, Majorie Vital, Yahya Hashim, Hamid Kani, Jessica Urbano Ramirez, Zainab Deen, Nura Jemal, Jeremiah Deen, (third row left to right) Yasin El-Wahabi, Firdaws Hashim, Hashim Kedir, Debbie Lamprell, Ernie Vital, Sakina Afrasehabi, Denis Mur-phy, Raymond ‘Moses’ Bernard, Biruk Haftom, (fouth row left to right) Yaqub Hashim, Mehdi El-Wahabi, Ligaya Moore, Nur Huda El-Wahabi, Victoria King, Mo-hammed Amied Neda, Maria del Pilar Burton, Hesham Rahman, Gary Maunders, (fifth row left to right) Alexandra Atala, Vincent Chiejina, Steve Power, Rania Ibrahim, Fethia Hassan, Hania Hassan, Fathia Ahmed Elsanousi, Abufras Ibrahim (silhouette), Isra Ibrahim (silhouette), (sixth row left to right) Mariem Elgwahry, Eslah Elgwahry (sil-houette), Mohamednur Tuccu, Amal Ahmedin, Amaya Tuccu-Ahmedin, Amna Mahmud Idris, Abdeslam Sebbar (silhouette) , Joseph Daniels (silhouette), Logan Gomes, (seventh row left to right) Omar Belkadi, Farah Hamdan, Malak Belkadi (sil-houette), Leena Belkadi (silhouette), Abdulaziz El-Wahabi, Faouzia El-Wahabi, Fatemeh Afrasiabi, Kamru Miah, Rabeya Begum, (eighth row left to right) Mohammed Hamid, Mohammed Hanif, Husna Begum, Bassem Choukair, Nadia Choucair, Mierna Choucair, Fatima Choucair, Zainab Choucair and Sirria Choucair
‘Systemic dishonesty’ from manufacturers
The report officially lifted the curtain on the businesses responsible for the cut-price refurbishment of Grenfell Tower in 2016, which saw dangerously flammable polyethylene-cored aluminium cladding panels plastered to the exterior of the high-rise building.
Sir Martin said there had been ‘systematic dishonesty’ on the part of manufacturers involving ‘deliberate manipulation’ of the testing processes and ‘calculated attempts to mislead’ clients into thinking that their products complied with guidance – which in fact advised against their use.
The deadly cladding panels – cited as the main reason why flames shot up the side of the building during the Inquiry’s first report, published in 2019 – were manufactured by French firm Arconic.
The report officially lifted the curtain on the businesses responsible for the cut-price refurbishment of Grenfell Tower in 2016, which saw dangerously flammable polyethylene-cored aluminium cladding panels plastered to the exterior of the high-rise building. Pictured: A composite photograph showing how the fire swept through Grenfell Tower in 2017
Sir Martin said there had been ‘systematic dishonesty’ on the part of manufacturers involving ‘deliberate manipulation’ of the testing processes and ‘calculated attempts to mislead’ clients into thinking that their products complied with guidance
The product was deemed as a low-cost alternative to rival brands, which appealed to cash-strapped councils.
Yet the firm knew about its potentially catastrophic shortfalls during a failed fire test.
However, it did not disclose that detail and obtained a certificate from the British Board of Agrement (BBA) for its cladding in 2008 – effectively falsely giving the doomed product the green light for use in high-rise buildings in the UK.
The inquiry report concluded Arconic and its technical manager Claude Wehrle had ‘deliberately and dishonestly concealed’ that information.
But he declined to give evidence to Sir Martin’s probe. In a scathing assessment, the inquiry chairman wrote: ‘If Mr Wehrle had given evidence in person he would have had an opportunity to respond to the suggestion… Nonetheless, the evidence we have seen, which includes his statement, leaves us in no doubt that that is what he did.’
Arconic sales manager Deborah French was found by the inquiry to have failed to pass on information about the products’ defects to any of her customers.
Other firms admonished included Celotex, which was responsible for the insulation panels that were installed over most of the tower’s facade during the refurbishment, and Irish manufacturer Kingspan, who provided the remainder.
Celotex – owned by the French giant Saint-Gobain – initially struggled to get its material to pass fire safety tests due to their releasing toxic gas.
But Sir Martin said the British-based company manipulated fire tests to make it erroneously appear as though its insulation boards were safe. They were not.
He said Celotex ’embarked on a dishonest scheme to mislead its customers and the wider market’.
Kingspan was also found to have lied about the credentials of its product.
Tests performed in 2007 and 2008 on systems incorporating the then current form of its K15 panels were ‘disastrous’.
A senior employee at Kingsplan told another ‘all we do is lie’ when discussing criticism that their product was not fire-safe.
Regardless, Kingspan did not withdraw the product from the market.
Certification bodies gave credence to cladding
One of the reasons manufacturers were able to exploit the UK market was due to the veneer of respectability bestowed on their ill-performing products by certification bodies.
The British Board of Agrement (BBA) was the commercial organisation charged with certifying the compliance of products with relevant legislation.
Its certificates were accepted in the industry largely without question, but its procedures for establishing a product’s claims were ‘neither wholly independent nor rigorous,’ the inquiry found.
People receive treatment at the scene of the Grenfell Tower fire in West London in June 2017
The BBA issued misleading certificates to both Arconic and Kingspan for their dodgy products because of its own incompetence and lack of proper system checks.
Sir Martin found the underlying problem was that the BBA failed to manage the conflict between ‘the need to act as a commercial organisation in order to attract and retain customers and the need to exercise a high degree of rigour and independence in its investigations in order to satisfy those who might consider relying on its certificates’.
Kingspan also successfully obtained a certificate from the industry body Local Authority Building Control (LABC) that backed up its false claims.
Sir Martin said the LABC was consequently also ‘the victim of dishonest behaviours on the part of unscrupulous manufacturers’.
‘Seeds of disaster sown’ in deregulation
Sir Martin accused David Cameron’s coalition government of failing to ensure public safety as it embarked on a programme of deregulation of fire standards.
The report found the Department for Communities and Local Government, which was in charge of building regulations, had been an ardent supporter of cutting bureaucracy – leading to concerns it would pave the way for flammable materials to be used in construction.
Civil servants working for then-Communities Secretary Eric Pickles said they felt unable to raise concerns.
Sir Martin said any fears were ‘ignored, delayed or disregarded’ by the Government, which had ‘failed to discharge’ its responsibilities to ensure public safety – even after the Camberwell fire in 2009.
The report said: ‘It is disappointing that when officials became aware of matters which posed serious risks to life, effective steps were not taken to draw those risks to the attention of ministers…That is where the seeds of the disaster were sown.’
‘Serious deficiencies in refurb oversight’
At regular intervals during the refurbishment of Grenfell Tower, other organisations had the opportunity to stop and intervene.
It did not happen adequately to avert disaster.
Rydon was the lead contractor for the £10 million renovation. But Sir Martin said it was similarly culpable as the manufacturers because of its ‘casual attitude’ throughout the project, and because it gave ‘inadequate thought to fire safety’.
Survivors of the Grenfell Tower fire speak to the media after the publication of the inquiry report
Sir Martin said lead contractor Rydon was similarly culpable as the manufacturers because of its ‘casual attitude’ throughout the building’s renovation project, and because it gave ‘inadequate thought to fire safety’
Sir Martin said its systems for managing the design work ‘did not ensure that its subcontractors and consultants properly understood their different responsibilities’.
And he said Kent-based Rydon did not understand where responsibility for individual decisions lay and as a result it failed to coordinate the design work properly.
Architects Studio E were responsible for the design of the external wall and the choice of materials used in the renovation.
Sir Martin accused them of bearing ‘a very significant degree of responsibility for the disaster’, of failing to recognise the aluminium panels were dangerous and that the insulation material was combustible.
Although the local Tenant Management Organisation – who ran Grenfell – wanted to reduce the cost by using aluminium composite material rainscreen panels, Sir Martin said it was the responsibility of Studio E to determine whether the use of such material would enable the building to comply with regulations.
Studio E also failed to recognise that Celotex insulation was combustible and not suitable for use on a building over 18 metres in height in accordance with statutory guidance.
And cladding contractor Harley ‘failed in many respects to meet the standards’ expected of it, Sir Martin said.
The firm ‘did not concern itself sufficiently with fire safety,’ he said.
The report found its relationship with Arconic meant it was able to offer the contractors a cost reduction and that the flammable panels would be chosen for purely financial reasons.
Sir Martin said: ‘Safety of people in the built environment depends principally on a combination of three primary elements – good design, the choice of suitable materials, and sound methods of construction, each of which depends in turn in a large measure on a fourth – the skill, knowledge and experience of those engaged in the construction industry.
‘Unfortunately…at the time of the…fire there were serious deficiencies in all four of those areas.’
‘Bullying overlord’ dismissed residents
Grenfell Tower was owned by the council, but run by a Tenant Management Organisation (TMO) – and so, of the two, it was the latter which was particularly singled out for criticism by the inquiry report.
The TMO was plagued by a poor approach to carrying out repairs, and hostility towards some of the residents in the 120-apartment block.
Addressing the relationship between Grenfell Tower landlords and residents, the report said: ‘We have concluded from all the evidence that, from 2011 to 2017, relations between the TMO and many of the residents of Grenfell Tower were increasingly characterised by distrust, dislike, personal antagonism and anger.
‘Some, perhaps many, occupants of the tower regarded the TMO as an uncaring and bullying overlord that belittled and marginalised them, regarded them as a nuisance, or worse, and failed to take their concerns seriously.
Occupants of the tower regarded the Tenant Management Organisation, which ran the building, as an uncaring and bullying overlord that belittled and marginalised them
Bereaved relatives attend a press conference today amid the inquiry’s damning report
‘For its part, the TMO regarded some of the residents as militant troublemakers led on by a handful of vocal activists, principally Edward Daffarn, whose style they found offensive.
‘The result was a toxic atmosphere fuelled by mistrust on both sides.’
When the worst happened, the TMO was catastrophically ill-equipped to deal with it.
The report found its Emergency Plan for Grenfell Tower was out of date and incomplete and did not reflect the changes brought about by the refurbishment.
It also failed to collect crucial information about its vulnerable residents.
It meant that on the night, information available to the TMO about who was in the building and their individual needs in the event of an evacuation was ‘incomplete’.
The TMO also employed an under-qualified and inexperienced person, Carl Stokes, to carry out fire risk assessments.
His methods ‘suffered from serious shortcomings’, including often failing to check whether the TMO had taken action to respond to identified risks.
London Fire Brigade officers had also expressed concerns about his competence, but the TMO ‘continued to rely uncritically on him’, the report said.
Heroic fire brigade ‘gravely’ unprepared
The first phase of the inquiry focused on what happened on the night, and found the London Fire Brigade was plagued with ‘institutional failures’ and its preparation for a Grenfell-style inferno was ‘gravely inadequate’.
And it said lives were probably lost because crews and 999 operators wasted ‘the best part of an hour’ telling the block’s occupants to ‘stay put’ in their flats – before realising the blaze was wildly out of control.
Yesterday’s report added that a tower block fire in Camberwell, south London, in 2009 which killed six people when cladding caught fire, ‘should have alerted the LFB to the shortcomings in its ability to fight fires in high-rise buildings’.
The report identified that firefighters were unable to distinguish between different types of hydrant while tackling Grenfell, and that there was a lack of proper training in this area.
Sir Martin said it was a ‘significant’ shortcoming that LFB failed to recognise the possibility that in the event of a fire in a high-rise building, a large number of calls seeking help, both from within and outside the building, might be generated.
Ministers ignored warnings from 90s
Sir Martin’s report identified plenty of warning signs about the dangers of external building cladding.
In 1991, residents at Knowsley Heights in Liverpool escaped with their lives after their tower block caught fire.
It had been covered in cladding during a renovation, which blazed when furniture dumped at the base of the building was set alight.
In 1999, a fire swept through another high-rise block of flats in North Ayrshire, Scotland.
A man died and five others were injured, with witnesses reporting the cladding acting as an effective conductor for the blaze.
Sir Martin said the Government ‘failed to heed the warning’ of the Environment and Transport Select Committee in December 1999 six months after the Ayrshire blaze – that it ‘should not take a serious fire in which people were killed before steps were taken to minimise the risks posed by some external cladding systems’.
