When Grenfell Tower in Kensington caught fire on the night of 14th June 2017, fire and smoke spread more quickly than expected because a dangerous cladding system had been installed in a botched effort to improve the council flats. The cladding was flammable and the gaps between the cladding panels and the original concrete walls created chimney vents to accelerate smoke.
That night 70 people lost their lives in the building, some trapped and some following fire brigade orders to stay put. Two more people died later as a result of the fire.
On 15th June 2017, the day after the fire, the then prime minister Theresa May announced a public inquiry.
The Grenfell Tower Inquiry was set up on 15th August 2017 with Sir Martin Moore-Bick, a former Lord Justice of Appeal, in the chair. Hearings for Phase 1 began in May 2018 and concluded in December 2018. The chairman published his Phase 1 report in October 2019.
Phase 2 hearings concluded in November 2022 and the final report was published in September 2024, cataloguing a long list of failings from across the supply chain.
The inquiry blamed multiple parties for the 72 deaths including the contractors, product suppliers, designers, the tenant management organisation and even the government itself.
“Not all of them bear the same degree of responsibility for the eventual disaster,” Moore-Bick said, “but as our reports show, all contributed to it in one way or another. In most cases through incompetence, but in some cases through dishonesty and greed.”
He said: “We found that there had been systematic dishonesty on the part of manufacturers involving deliberate manipulation of the testing processes and calculated attempts to mislead purchasers into thinking that what were combustible materials complied with the provisions of the statutory guidance that advised against their use.
“That dishonest approach to marketing was compounded by the failures of two of the bodies that provided certificates of compliance with the building regulations and statutory guidance – the British Board of Agrément (BBA) and Local Authority Building Control – to scrutinise the information provided to them with sufficient care and to exercise the degree of rigour and independence that was to be expected of them.”
The BBA, although a certification body, is also a commercial organisation and the manufacturers of the products it certifies are also its customers. The report says: “We accept that in the case of Arconic and Kingspan, the BBA was the victim of dishonest behaviour on the part of unscrupulous manufacturers, but if it had maintained robust processes that could not have happened.”
It adds that BBA had “an inappropriate desire to please its customers” and “accepted forms of wording proposed by them for inclusion in certificates that were wrong and misleading”.
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The inquiry also singled out the once highly-respected Building Research Establishment (BRE) for damning criticism.
In the aftermath of the disaster it was quickly established that the trigger was a fridge freezer in flat 16 catching fire. The deaths were caused by the spread of flames accelerating by the flammable core of the rainscreen cladding fixed to the building as part of a refurbishment in 2015 and toxic gases spreading through the voids into other flats.
No one involved in the refurbishment has been prepared to accept responsibility for specifying the dangerous cladding system but the inquiry found that the flammable Arconic aluminium composite material (ACM) panels were chosen as rainscreen to keep down the costs.
“Everyone involved in the choice of the materials to be used in the external wall thought that responsibility for their suitability and safety lay with someone else,” the report says.
Moore-Bick set out some of the issues of rife incompetence across the refurbishment project team: “Studio E [the architect] had no experience of overcladding a high rise building. It failed to recognise, as a reasonably competent architect should have done, that the insulation and rainscreen chosen were combustible and unsuitable for that purpose.
“Neither Rydon as principal contractor nor Harley, its cladding subcontractor, was aware of the properties of the materials specified for use in the refurbishment although Harley, as a specialist subcontractor dealing with cladding, should have been; and Rydon as principal contractor had its own responsibility to ensure the materials were suitable.
“One of the problems that afflicted the refurbishment was a failure on the part of all concerned to understand where responsibility for any particular decision lay. That was especially the case in relation to choice of the rainscreen.
“We find that Studio E, Rydon and Harley all took an unacceptably casual approach to contractual relations. None of their employees engaged on the project understood the relevant provisions of the building regulations, the statutory guidance or such guidance from industry sources as were then available.
“That might not have mattered quite so much if proper advice had been taken from a competent and experienced fire engineer or if Building Control had performed its task properly.”
WHO TAKES THE BLAME?
The inquiry found that although responsibility is not equally distributed, the following organisations each “contributed in one way or another” to the Grenfell Tower disaster:
- the tenant management organisation
- the Royal Borough of Kensington & Chelsea
- the manufacturers and suppliers of the materials used in the 2015 refurbishment
- those who certified the products as safe to use in high rise buildings
- the principal contractor, Rydon, and some of its subcontractors, in particular Harley Curtain Wall and its successor Harley Facades
- some of the consultants, in particular fire engineer Exova Warringtonfire and Local Authority Building Control
“WASN’T ME, GUV” – THE MANUFACTURERS HAVE THEIR SAY
According to Sir Martin Moore-Blick, chair of the Grenfell Tower Inquiry, Arconic, Celotex and Kingspan displayed “systematic dishonesty” and “deliberate manipulation” to get their products used in the 2015 refurbishment of Grenfell Tower. Here’s what they had to say in return:
Arconic
“Arconic’s subsidiary, Arconic Architectural Products SAS (AAP), supplied sheets of aluminium composite material that were used to manufacture the rainscreen for the Grenfell Tower refurbishment.
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“The fire was a terrible tragedy and as Arconic remembers the 72 people who died, our thoughts remain with the families, friends and all of those affected.
“AAP was a core participant in the inquiry and has acknowledged its role as one of the material suppliers involved in the refurbishment of Grenfell Tower.
“The company respects the Inquiry process. AAP cooperated fully with the work of the Inquiry and will continue to engage with further legal processes. Together with other parties, AAP has made financial contributions to settlements for those affected, as well as to the restorative justice fund.
“Throughout the inquiry, AAP has maintained a number of points:
- AAP sold sheets of aluminium composite material as specified in the design process. This product was safe to use as a building material, and legal to sell in the UK as well as the more than thirty other countries in which AAP customers purchased the product. We reject any claim that AAP sold an unsafe product.
- AAP regularly conducted tests of its materials using third-party testing bodies. Reports on these results were all publicly available, and AAP made these reports available to its customers.
- AAP did not conceal information from or mislead any certification body, customer, or the public.”
Kingspan
“We welcome the publication of [the] report which is crucial to a public understanding of what went wrong and why. It explains clearly and unambiguously that the type of insulation (whether combustible or non-combustible) was immaterial, and that the principal reason for the fire spread was the PE ACM cladding, which was not made by Kingspan.
“Kingspan has long acknowledged the wholly unacceptable historical failings that occurred in part of our UK insulation business. These were in no way reflective of how we conduct ourselves as a group, then or now. While deeply regrettable, they were not found to be causative of the tragedy.
“Kingspan has already emphatically addressed these issues, including the implementation of extensive and externally-verified measures to ensure our conduct and compliance standards are world leading.
“We remain committed to playing a leading role in providing safe and sustainable building solutions, including continuing to work with government and industry partners.”
Celotex
“Through its participation in the Inquiry process and its own internal investigations, Celotex Limited has sought to understand and learn from the issues raised by the fire. We are committed to playing our part in ensuring that no such tragedy occurs again.
“Our business’ response started immediately after the fire in June 2017. We conducted our own review to interrogate the circumstances in which the RS5000 product had been tested, launched and marketed… “Information was uncovered through the review that was previously unknown to the management of the company at the time of the Grenfell Tower fire. The company took appropriate action.
“Independent testing commissioned following the review demonstrated that the cladding system described in Celotex RS5000 marketing literature met the relevant safety criteria.
“Government testing in August 2017 showed that a cladding system incorporating RS5000 and a non-combustible aluminium cladding panel met the relevant standards. These systems were substantially different from that used at Grenfell Tower, which incorporated combustible cladding panels. Celotex Limited does not design and install cladding systems and did not do so at Grenfell Tower…
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“Since the fire, we reviewed and improved process controls, quality management and the approach to marketing within the Celotex business to address the issues discovered and ensure that the culture, systems and processes relating to product compliance and product safety meet industry best practice.”
Grenfell report recommends nationalising product certification
Construction Regulator would replace commercial bodies
Lying and cheating by construction product manufacturers and their collusion with incompetent product certification bodies were key factors in the fire that killed 72 people in Grenfell Tower.
The solution, the official inquiry has concluded, is total state intervention, taking over the whole certification process out of the commercial sector and making it a function of government.
The inquiry’s final report calls for the creation of a Construction Regulator, with much wider responsibilities than those given to the recently created Building Safety Regulator.
The report recommends that the Construction Regulator be given responsibility for the regulation of construction products including testing and certification and the regulation and oversight of building control.
It wants the Regulator to be responsible for collecting information, both in the UK and abroad, on matters affecting fire safety, exchanging information with the secretary of state and the fire and rescue services and maintaining a publicly available library of test data and publications.
“It is essential that those responsible for designing buildings have access to reliable information about the materials and products they wish to use,” the report states.
“Conformity assessment bodies provide a commercial service combined with an element of regulation, but the two functions do not sit easily together. Pressure to acquire and retain customers can all too easily lead such bodies to be less rigorous in their examination of products and materials and enforcing their terms of contracts than could reasonably be expected of bodies acting in the public interest.
“We therefore recommend that the Construction Regulator should be responsible for assessing the conformity of construction products with the requirements of legislation, statutory guidance and industry standards and issuing certificates as appropriate. We should expect such certificates to become pre-eminent in the market.”
The report also recommends that government address the fragmentation of its own responsibilities for regulating fire safety in the construction industry, which is currently spread across the Ministry of Housing, the Home Office and the Department for Business & Trade.
It recommends a single body responsible for all aspects of regulating matters affecting fire safety in the construction industry, reporting to a single secretary of state, answerable to parliament for all aspects of fire safety.
Other recommendations include the secretary of state reinstating the position of Chief Construction adviser (which was created in 2009 but abolished in 2015), only this time with a sufficient budget and staff to provide advice on all matters affecting the construction industry.
The inquiry also recommends revisions to Approved Document B, the building regulation in England covering fire safety matters within and around buildings. Ambiguity over its status appears to have been a factor in the choice of cladding for the 2015 Grenfell Tower refurbishment.
“We do not think that Approved Document B provides the information needed to design buildings that are safe in fire,” the report says.
“Approved Document B needs to be reviewed as a matter of urgency… It must then be kept under continuous review, together with the other Approved Documents, and amended annually or promptly whenever developments in materials or building methods make that desirable. It should be drafted conservatively to ensure, as far as possible, that compliance with it will provide a high degree of confidence that on completion of the work the building will comply with the Building Regulations.”
Residents still at risk
A week before publication of the final Grenfell Tower Inquiry report, investigations began into the role of rain screen cladding in the spread of another tower block fire in the capital.
The London Fire Brigade was called to the eight-storey Spectrum House on Freshwater Road in Dagenham at 02.44 hours on Monday 26th August.
It took 40 fire engines and around 225 firefighters more than eight hours to tackle the fire.
More than 80 people were evacuated from the building and at least 20 were rescued by firefighters; two were taken to hospital.
Residents had known for at least four years that they were in danger.
While Grenfell Tower’s cladding was aluminium composite material (ACM), the cladding on Spectrum House was high-pressure laminate (HPL), as used on Lakanal House, the Camberwell tower block in which six people died in a fire in 2009.
When Spectrum House caught fire it was covered in scaffolding and undergoing remediation works, including cladding replacement.
Grenfell report exposes BRE post-privatisation failings
Few organisations receive more damning criticism in the final report of the Grenfell Tower Inquiry than the Building Research Establishment, writes Phil Bishop.
One of the key recommendations of the Grenfell Tower inquiry in its phase 2 report is the creation of a new regulatory body to oversee the construction industry (including standards, regulations and expertise) and an office of chief construction adviser with a sufficient budget and staff to provide advice to government on all matters affecting the construction industry.
In effect, the report is calling for what amounts to the abolition of not just self-certification and third-party self-certification but its replacement by state certification.
This article was first published in the November 2024 issue of The Construction Index Magazine. Sign up online.
There was a body that might once have been equipped to take on that task, the Building Research Establishment (BRE). But – according to the Grenfell Tower inquiry phase 2 report – since its privatisation in 1997, that body has fallen spectacularly from grace and become utterly corrupted by commercialisation.
BRE began life in the 1920s as a government agency. It was privatised in 1997 but continued to advise the government on various technical matters, including fire safety, while also carrying out privately-funded research for commercial clients.
In Volume 2, Part 3, of the Grenfell Tower report, the inquiry notes that “BRE was widely recognised both nationally and internationally as a leader in fire safety. For many years before the fire at Grenfell Tower it was the only organisation in the UK capable of carrying out large-scale testing in accordance with BS 8414. BRE developed that test and published all three versions of BR 135, which set out the criteria against which data from tests carried out in accordance with BS 8414 should be assessed.”
But the report notes that much of the work carried out by BRE more recently “was marred by unprofessional conduct, inadequate practices, a lack of effective oversight, poor reporting and a lack of scientific rigour”.
The inquiry saw evidence of a “desire to accommodate existing customers at the expense of maintaining the rigour of its processes”. Although following its privatisation in 1997 BRE continued to work closely with the Department of Communities & Local Government, it consistently failed to notify the government of matters that might have required amendments to the building regulations.
This was despite the fact that a senior BRE employee, Brian Martin, was seconded to the department where he was responsible for official building regulations guidance.
The BRE was also careless in the way it carried out tests in accordance with BS 8414.
The report notes: “It did not identify carefully the materials delivered to the burn hall for individual tests, it did not ensure that they corresponded to the drawings of the system to be tested and did not ensure that the rig, as constructed and tested, accurately reflected the drawings that had been provided.”
There was confusion too over whether the drawings provided by the test sponsors represented the system in isolation or the system as it was intended to be incorporated into an actual building. Sometimes, drawings were not even provided until after the tests had been carried out.
“As a result of those defects in the system, reports of tests did not always correctly describe the system tested,” says the report.
“BRE took the position, repeated in all test reports, that the configuration of the system to be tested was entirely a matter for the sponsor of the test,” the report says. Hence insulation manufacturer Celotex was able to manipulate the testing process by introducing materials other than those described in the test report.
“Undue familiarity” between clients and BRE staff also allowed manufacturers to undermine BRE’s impartiality. For example, in 2007, BRE staff had unofficial discussions with Kingspan about the performance of its K15 rainscreen board following the disastrous result of a test on a system of which K15 had formed part.
“In keeping with Kingspan’s strongly expressed wishes, BRE agreed to say no more in its report than that the system as a whole had not met the criteria in BR 135, despite having commented privately to Kingspan that the insulation had been fully involved and had continued to burn even after the flame source had been extinguished,” says the report.
Evidence given to the inquiry also found that BRE staff effectively coached manufacturers on ways in which they could tweak test samples to get them to pass after they had previously failed.
A lot of this unprofessional behaviour was down to a lack of proper training says the report: “We have been critical of Mr Clark [Phil Clark, burn hall manager] for advising Celotex on ways in which it might improve its system following the test in February 2014, for failing to draw attention to the use by Celotex of magnesium oxide boards in the system tested in May 2014 and for giving advice to Kingspan during the test conducted for it in March 2014. However, he had received no training from BRE of any kind on what was required by way of independence and impartiality.”
The Grenfell Tower fire was preceded by several fires in high-rise blocks going back more than 30 years and BRE had carried out investigations into these events on behalf of the government. It usually concluded that each of these fires provided important lessons for the future.
However, the Grenfell Tower inquiry found that BRE’s investigations “were characterised by a lack of analysis and were at best superficial. Most reports revealed very little that would enable one to discern patterns or trends or even understand what had caused or contributed to any particular fire,” the report concludes.
This article was first published in the November 2024 issue of The Construction Index Magazine. Sign up online.
“BRE’s reports into the major fires at Knowsley Heights (1991), Garnock Court (1999) and The Edge (2005) and its preliminary report into the fire at Lakanal House (2009) were far from comprehensive and in each case failed to identify or assess important contributory factors.”
And while BRE referred to ‘important lessons’, the inquiry concluded that “no-one at BRE was able to describe what those lessons actually were”.
If BRE’s systems and management were sloppy, so too was its scientific work, concludes the inquiry report. “For example, reports produced under the cc1924 project conflated Class 0 and limited combustibility when describing the regulatory requirements and guidance,” says the report. “That was a fundamental error that was repeated by BRE when reporting on the fire at Lakanal House and in the work done for the department by the BRE on external fire spread in 2015.”
It adds: “That particular piece of work, which involved experimental testing and a background research paper, was seriously inadequate. It was deeply flawed in almost every respect, lacked any scientific value and purported to draw positive conclusions about the effectiveness of the regulations and guidance that could not sensibly have been reached on the basis of the work that had been carried out.”
Invited to respond, BRE said: “BRE welcomes the publication of the Grenfell Tower Inquiry’s report and fully supports the process of ensuring that a tragedy such as this can never happen again. We have nothing but the deepest sympathy for the friends and families of those who lost their lives, and all those whose lives were changed by the fire.
“We will be reviewing the report and its recommendations and will continue to work constructively with government to ensure the new building safety and testing regime delivers on the findings of the Inquiry’s report and is fit
for purpose.”
Hospitals – the next fire disaster?
Since the Grenfell Tower fire, attention has been focused on the threat posed by unsafe cladding. But in 2017, a week after the disaster, The Construction Index spoke to a specialist fire-protection contractor who warned that a lack of inspection and regulation of the fire-stopping industry meant that many new and refurbished buildings were unprotected (writes David Taylor).
Passive fire protection products, including fire doors, intumescent coatings and fire-stops, are designed to inhibit combustion and prevent the uncontrolled spread of fire and smoke within buildings.
But despite Building Regulations requiring minimum levels of fire protection within buildings, The Construction Index heard that the application and installation of passive fire protection is poorly understood and that there is no effective system to ensure that it is installed and maintained correctly.
In particular, inadequate fire protection had been identified at a number of new NHS hospitals – but this was “just the tip of the iceberg”, according to our source.
In September this year, in advance of ‘Fire Door Safety Week’, the British Woodworking Federation (BWF) published a report that found that despite a “concerning” increase in fires across NHS trusts, 52% of people still consider hospitals the safest buildings due to their fire prevention measures.
Official NHS data relating to the costs of providing, maintaining, and servicing the NHS estate revealed that 1,372 fires were recorded by NHS trusts in 2022/23, 18% more than the previous year.
“Our survey found that 52% of people consider hospitals as the buildings they would feel safest in the event of a fire despite NHS data reporting a concerning rise in fire incidents,” said BWF chief executive Helen Hewitt.
This article was first published in the November 2024 issue of The Construction Index Magazine. Sign up online.
In 2023, as part of an awareness campaign, BWF surveyed 1,000 people with responsibility for fire door specification, installation, and maintenance (including landlords) regarding the introduction of the Building Safety Act.
The research found that 30% of respondents were unsure or did not understand their responsibility with regards to the new legislation and pointed to the need for more support.
“It’s clear more needs to be done to ensure that building owners fully understand their role and responsibilities over fire safety,” said Hewitt.
“Through our Fire Door Safety Week and ‘Be Certain, Be Certified’ campaigns, we aim to increase awareness and understanding of the vital role that fire doors play in the event of a fire.”
But if a recent study by the Institute for Fiscal Studies (IFS) is anything to go by, identifying and remedying inadequacies in fire doors and other passive fire protection systems might not be the priority for NHS estate managers that it should be.
The IFS report highlights a “growing financial and operational crisis” facing NHS estates and notes that, over the past decade, the maintenance backlog for NHS facilities has doubled.
“The required investment to eliminate the NHS England maintenance backlog has soared from £5.5bn in 2013/14 to a staggering £12.5bn in 2022/23,” says the report.
“Healthcare leaders are navigating complex funding rules, which hampers their ability to maintain equipment and buildings. This inaction leads to severe operational challenges, affecting patient safety and staff satisfaction. Deteriorating infrastructure – evident in broken lifts, leaking roofs and structural risks from materials like reinforced autoclaved aerated concrete (RAAC) – poses significant threats to both patients and staff.”
