On 4 September 2024, the Inquiry published its final report detailing its findings on the factors that led to the Grenfell Tower fire which took place on 14 June 2017. The final findings in this report details the chain of failures on the part of the Government and several other bodies in the private sector who had all contributed one way or another to the fatal disaster which took the lives of 72 residents. The report finds that the disaster could have been avoided but for the negligence of those responsible.
Some of the main findings of the 17,000 page report by Sir Martin Moore-Bick can be summarised below.
Government’s knowledge of risks relating to flammable cladding
Following the 11-storey Knowsley Heights tower block fire in Merseyside in 1991, government bodies were warned about cladding and the risks it imposed but took no steps to identify the risks relating to combustible cladding panels and materials. There was another fire at Garnock Court in North Ayrshire 7 years after the Knowsley Heights incident, albeit the issues were still not addressed despite a committee of MPs raising concerns. The use of external cladding systems was never banned as it had already been classed as meeting a British safety standard.
The relevant bodies were made aware of the severity of issues arising from the use of cladding. Safety tests carried out in 2001 revealed that the type of cladding of concern ‘burned violently’, however, these findings were kept confidential and the government failed to take any steps to present regulations in this regard or to take any further action.
Systematic dishonesty in relation to materials used
Grenfell Tower had undergone refurbishment works between 2015 – 2016 prior to the fire occurring in relation to several issues raised by residents in the building. As part of the refurbishment works, the building received new aluminium composite rain screen cladding. The purpose of the cladding was to improve heating and energy efficiency as well as improving the external appearance. Part 3 of the report investigates the testing and marketing of the main products used in the refurbishment and with findings of systematic dishonesty by those who made and sold the cladding. The report singled out Celotex which manufactured the combustible RS5000 foam insulation for making calculated attempts to mislead purchasers. The report also pointed fingers at Arconic Architectural Products stating that it had deliberately manipulated the testing process to conceal the true extent of the danger of using its Reynobond 55 PE rainscreen panels which were installed onto the exterior of the building. These companies embarked on a dishonest scheme to satisfy customers that such combustible materials complied with statutory guidance and incorrectly produced certificates of compliance with building regulations. Further, the local authority’s building control department had failed to properly scrutinise the information provided to them.
Major failings on the part of the Tenant Management Organisation (TMO), the Local Council and the Construction Industry
Several department organisations and private sector construction bodies have all played a part in the tragedy whether that be as a result of negligence to carry out duties correctly or due to financial greed.
The relationship between the residents of Grenfell and the TMO were marked by distrust, antagonism and increasingly bitter confrontation which led to the TMO’s neglect and failure on its part to observe its basic responsibilities. Due to the breakdown of their relationship, the residents of the building were seriously let down by the TMO who had a duty of management of fire safety within the tower as well as many other obligations. The residents had raised concerns about fire safety within the building, yet the TMO persistently failed to give sufficient importance to the demands of fire safety, particularly the safety of vulnerable people and failure on the part of the council to scrutinise this aspect the TMO’s activities adequately. Part of the failure stems from the lack of communication between the TMO and the council to keep informed of matters affecting fire safety.
Furthermore, the refurbishment works carried out at Grenfell were ruled to be disturbing in many aspects. Firstly, the regulatory context in which the work was carried out was deemed unsatisfactory because the statutory guidance and building regulations were not sufficiently followed. The report finds that the TMO had manipulated the process of appointing an architect to design the refurbishment in order to avoid the need to invite open tenders for the architectural services it did and rather, selectively chose a known architect that was known to it, whom had no experience of cladding a high-rise building. This turned out to have significant consequences as the appointed architect failed to recognise as a reasonably competent architect should have done that the materials chosen for the refurbishment were combustible and unsuitable for that purpose. Not only that, but materials were selectively chosen to keep costs down. These materials were categorically unsuitable and highly risk prone.
Recommendations
The report concludes with its recommendations to prevent such a tragic incident from occurring and urges relevant authorities to take immediate action in this regard. The conclusions are that more can and should be done to bring fundamental change in the attitudes and practices of the construction industry to ensure future buildings, in particular high rise buildings are safe for those who live and work in them. These changes will ensure that dangerous materials are banned and cannot be used in construction in the future and for a construction regulator to oversee all aspects of the construction industry, bringing responsibility for all aspects of fire safety under one government department. Further it is recommended that establishing a body of professional fire engineers who are properly regulated and the introduction of mandatory fire safety strategies for higher risk buildings as well as a licensing scheme for contractors wishing to undertake the construction or refurbishment of high risk buildings will enable proper and sufficient regulation of all parties involved.
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