The panel made the following statement.
Sir Martin Moore-Bick:
Today the Panel in the Grenfell Tower Inquiry is publishing its final report dealing with
the root causes of the fire.
In Phase 1 of the investigations I examined the events of 14 June 2017: how the fire
started, how it escaped from the flat where it had begun and how it spread over the
whole building with tragic consequences. My report on that series of events was
published on 30 October 2019. In the second phase of the Inquiry the Panel has been
investigating the underlying causes of the fire with a view to identifying where mistakes
were made and ensuring that a similar disaster cannot occur again.
This second part of the investigations has taken longer than we had hoped, partly
because of the broad scope of our Terms of Reference and partly because, as our
investigations progressed, we uncovered many more matters of concern than we had
originally expected.
As we discovered, it is not possible properly to understand the causes of the fire
without understanding the way in which knowledge of the materials and methods of
construction employed in the refurbishment developed over the course of time, what
the government and others learnt about them and how the regulations and guidance
relating to their use developed during the same period. The information obtained in
that part of our investigations provided the background to our examination of the
refurbishment itself and the various decisions taken in the course of it, particularly in
relation to the selection of materials.
In addition, it has been necessary for us to examine the way in which fire safety at
Grenfell Tower was managed, including the arrangements for fire risk assessments
and the response to them, as well as the relationship between the Tenant
Management Organisation and the residents of the tower.
The firefighting operations of the London Fire Brigade were considered in detail in my
first report, but a number of questions relating to organisation and training could not
be answered at that stage and were deferred for consideration in Phase 2.
Also deferred to Phase 2 were certain questions relating to the development of the
fire, including the relative contributions of the different materials used in the cladding.
Another important aspect of our Terms of Reference was to investigate the response
of the authorities to the emergency.
Finally, but most importantly, it was necessary for us to investigate in as much detail
as the evidence would allow the circumstances surrounding the deaths of those who
perished in the fire.
The report we are publishing today contains our findings on all these and other
matters. However, the simple truth is that 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. They include the government, the Tenant Management
Organisation, the Royal Borough of Kensington and Chelsea, those who manufactured
and supplied the materials used in the refurbishment, those who certified their
suitability for use on high-rise residential buildings, the architect, Studio E, the principal
contractor, Rydon Maintenance Ltd, and some of its sub-contractors, in particular,
Harley Curtain Wall Ltd and its successor Harley Facades Ltd, some of the
consultants, in particular the fire engineer, Exova Warringtonfire Ltd, the local
authority’s building control department and the London Fire Brigade. Not all of them
bear the same degree of responsibility for the eventual disaster, 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.
The failings can be traced back over many years and our efforts to get to the bottom
of what went wrong and why, account for the length of our report and the time it has
taken us to produce it. However, if an inquiry of this kind is to produce anything of
value, it is necessary for those who can influence the future direction of the
construction industry, the fire and rescue services, the management of fire safety in
buildings and resilience planning to understand exactly where mistakes were made
and how they can be avoided in the future.
The report is divided into 14 parts, broadly by reference to related subjects. Some
Parts contain several chapters; some only one. As with the Phase 1 report, it begins
with an Introduction followed by an Executive Summary. Although the Executive
Summary runs to 24 pages, the length of the report means that it can touch on only
the most significant elements of our conclusions. However, it should assist readers in
finding their way around the report.
Part 2 describes significant events that provided the background to the fire. It begins
by explaining how the regulations and guidance in force at the time of the
refurbishment came into being and the way in which the reaction to fire of materials
used in the construction of modern high-rise buildings was tested. We then consider
the involvement of the government in the form of the Department for Communities and
Local Government, the way in which it sought to monitor the causes of fires when they
occurred and, most importantly, the warning signs that were emerging from as early
as 1991 that some kinds of materials, in particular aluminium composite material
panels with unmodified polyethylene cores, were dangerous. We find that there was a
failure on the part of the government and others to give proper consideration at an
early stage to the dangers of using combustible materials in the walls of high-rise
buildings. That included failing to amend in an appropriate way the statutory guidance
on the construction of external walls. That is where the seeds of the disaster were
sown.
In Part 3 we set out our findings about the testing and marketing of the main products
used in the refurbishment, the Reynobond panels, the Celotex RS5000 insulation and
the small amount of Kingspan K15 insulation. We discovered 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 failure of two of the bodies that provided certificates of compliance
with the Building Regulations and statutory guidance, the British Board of Agrément
and Local Authority Building Control, to scrutinise the information provided to them
with sufficient care and exercise the degree of rigour and independence that was to
be expected of them.
The Tenant Management Organisation was at the heart of events leading up to the
fire. In Part 4 we make our findings about its relationship with the residents of Grenfell
Tower. We find that the organisation was badly run and failed to respond to criticisms
of its treatment of residents in independent reports produced in 2009. It is clear that
for some years before the fire relations between the TMO and residents were marked
by distrust, antagonism and increasingly bitter confrontation. We find that for the TMO
to have allowed the relationship to deteriorate to such an extent reflects a serious
failure on its part to observe its basic responsibilities.
Part 5 of the report is concerned with the management of fire safety at the tower.
Again, we find that residents were badly let down. The picture is one of a persistent
failure to give sufficient importance to the demands of fire safety, particularly the safety
of vulnerable people, and a failure on the part of the Council to scrutinise that aspect
of the Organisation’s activities adequately. Part of the reason for that was the failure
of the chief executive, Robert Black, to ensure that the board of the TMO and the
Council were kept properly informed of matters affecting fire safety. That was despite
periodic expressions of concern by the LFB about compliance with the Fire Safety
Order, all of which should have been drawn to their attention.
The TMO’s failure to attach sufficient importance to fire safety is illustrated by its
reliance on a single person, Carl Stokes, as fire risk assessor for its entire estate,
despite his lack of qualifications and experience, by its failure to carry out necessary
remedial work identified in fire risk assessments promptly, by its failure to provide
measures to mitigate the absence of an effective smoke ventilation system and by its
failure to introduce appropriate arrangements for inspecting and maintaining fire
prevention systems, in particular self-closing devices on the entrance doors to
individual flats. In addition, the TMO failed to maintain a reasonably accurate record
of those residents of the tower who were vulnerable for one reason or another and
likely to need help to escape if a fire occurred.
Part 6 contains our findings about the refurbishment itself and again, the picture is
disturbing. First, the regulatory context in which the work was carried out was in our
view unsatisfactory because the statutory guidance, which was treated by many in the
construction industry, including those engaged on the refurbishment, as containing a
sufficient statement of what was required, did not make it clear enough that it was
subject to the overriding requirements of the Building Regulations. That was a
particular problem in relation to the rainscreen panels, which, although they satisfied
the requirement in the guidance for a material with a Class 0 surface, contained a
highly combustible core.
But that is only the beginning. The Tenant Management Organisation, as the client,
manipulated the process of appointing an architect to design the refurbishment to
avoid the need to invite open tenders for the architectural services. It did so because
it wanted to appoint Studio E, the architect for the existing Academy and Leisure
Centre project, despite the fact that it had no experience of overcladding a high-rise
building. That turned out to have significant consequences, because Studio E failed to
recognise, as a reasonably competent architect should have done, that the insulation
and rainscreen chosen for the refurbishment were combustible and unsuitable for that
purpose. ACM panels were chosen as the rainscreen to keep down the cost. Neither
Rydon, the principal contractor, nor Harley, its cladding sub-contractor, was aware of
the properties of the materials specified for use in the refurbishment, although Harley,
as a specialist cladding sub-contractor, 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 the choice of the rainscreen. The generally prevailing
view was that, since ACM panels had been used on other buildings without apparent
problems, they were suitable for use on the tower, but no one was prepared to accept
responsibility for having chosen them and when questioned everyone who was asked
said that someone else had been responsible for ensuring that they were suitable. 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 was 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. In fact, the Tenant Management Organisation did instruct Exova
Warringtonfire to produce a fire safety strategy for the refurbishment, which should
have included advice on the effect of the overcladding and the compliance of the
external walls with functional requirement B4(1) of the Building Regulations. Exova
produced three versions of a fire safety strategy, but each version was stated to be a
draft and was incomplete because it did not deal with that question, which it said would
be covered in a future issue of the report. It was clear, therefore, that the fire safety
strategy was incomplete, but no one asked Exova to finish its work, nor did anyone
provide it with details of the proposed cladding to enable it to do so. Exova itself failed
to ask for the missing information or to complete the work it had been instructed to
carry out. The failure to obtain a final report was probably critical, because, if Exova
had considered the proposed cladding, it should, and probably would, have identified
the fact that the insulation and rainscreen did not comply with the statutory guidance.
In Part 8 we set out our findings on the management and training of the London Fire
Brigade in the years leading up to the fire. That part of our investigations represented
a continuation of the work started in Phase 1, in which I described the response of the
LFB on the night. I was critical of certain aspects of that response, in particular, the
way in which the control room handled calls from people trapped in the building and
the actions of some of the incident commanders who had not been properly trained to
deal with a fire of that nature. That made it necessary for us to examine the LFB’s
management and training in the period leading up to the fire as well as the way in
which it made use of the information available to it.
In this report we find that there were deficiencies in the organisation and management
of the control room, the training of control room officers and in the commissioning and
delivery of training to operational crews, in particular in relation to incident command.
There were also deficiencies in the collection of information needed to enable crews
to prepare effectively to respond to fires in individual buildings. The primary cause of
those problems was a chronic lack of effective leadership, combined with an undue
emphasis on process and an attitude of complacency.
We have also returned to investigate some aspects of firefighting operations on the
night of the fire on which I was unable to make findings in Phase 1, in particular,
problems with communications and the supply of water.
I shall return to Part 9 in a moment but for now I move to Part 10, in which we examine
the authorities’ response to the fire. Once again, we have found that those who lost
their homes as a result of the fire were badly let down by the organisations that should
have provided the support they desperately needed. The primary responsibility for that
lay with the Council, which, as a Category 1 responder under the Civil Contingencies
Act, should have had plans in place to enable it to respond effectively to the
emergency. In the event, however, it had failed to put in place suitable plans or provide
the training to its staff that was required to enable it to respond effectively to the
situation it faced. In addition, its chief executive was ill-suited to taking control of what
was undoubtedly a very serious challenge. The Council did not have the capacity to
identify those who needed accommodation and other important forms of assistance;
nor did it have arrangements in place for communicating with those affected by the
disaster or the wider public. As a result, it was not capable of meeting the immediate
needs of those who had been displaced from their homes for food and shelter. In the
end it was local voluntary and community organisations that filled the gap by providing
rest centres and temporary shelter.
The London-wide resilience structures that were intended to enable the capital to
respond to an emergency affecting more than one borough did not operate effectively,
partly because they were not designed to provide central direction to the response and
partly because the Royal Borough of Kensington and Chelsea did not seek assistance
promptly. In the event, the government, in the form of a senior official in the
Department for Communities and Local Government, brokered an arrangement under
which the experienced Town Clerk of the City of London took control of the operation.
An important chapter of this Part records the evidence given by those who were
personally affected by the fire. We are aware that giving evidence, particularly giving
evidence in public, was a difficult and daunting experience. We should therefore like
to thank all of those who contributed to our investigations by giving evidence, both in
the form of witness statements and by being willing to talk about their experiences in
public. By doing so they ensured that we received the fullest possible account of the
events that unfolded in the days following the fire.
In Parts 11, 12 and 13 of the report we deal with a number of different matters,
including the experiments carried out by Professor Bisby and Professor Torero on the
materials used in the refurbishment. They confirm that the Reynobond ACM panels
were the primary reason for the fire’s devastating progress.
Part 14 contains our recommendations. Although some steps have already been
taken to respond to the many failures we have identified, we think that more can and
should be done to bring about a fundamental change in the attitudes and practices of
the construction industry. Only such a change can ensure that in future buildings in
general, and higher-risk buildings in particular, are safe for those who live and work in
them.
We think that in different ways implementation of our recommendations will improve
fire safety, particularly in high-rise buildings, and ensure that dangerous materials
cannot be used in construction in the future. They will also improve the efficiency of
fire and rescue services nationally. They include:
● the appointment of a construction regulator to oversee all aspects of the
construction industry;
● bringing responsibility for all aspects of fire safety under one government
department;
● the establishment of a body of professional fire engineers, properly regulated
and with protected status and the introduction of mandatory fire safety
strategies for higher-risk buildings;
● a licensing scheme for contractors wishing to undertake the construction or
refurbishment of higher-risk buildings;
● the regulation and mandatory accreditation of fire risk assessors;
● the establishment of a College of Fire and Rescue to provide practical,
educational and managerial training to fire and rescue services; and
● the introduction of a requirement for the government to maintain a publicly
accessible record of recommendations made by select committees, coroners
and public inquiries, describing the steps taken in response or its reasons for
declining to implement them.
I now return to Part 9 of the report which is the most personal Part and contains the
most difficult reading. It contains a detailed account of the circumstances surrounding
the deaths of those who perished in the fire. I did not refer to it earlier because it
seemed to me fitting to end these proceedings, as they began in May 2018, with a
reminder that the fire at Grenfell Tower was above all a human tragedy in which many
lives were lost, families were torn asunder, homes were destroyed, and a community
was shattered.
The detailed reconstruction we have provided will be for many one of the most
important parts of our report. Although it may make painful reading, those who lost
relatives and friends naturally feel a need to know as much as possible about their
loved ones’ last moments. I said on many occasions that I hoped we could find
sufficient facts to satisfy the coroner of the circumstances surrounding their deaths
and avoid the need for any further proceedings.
I am now able to say that we have been able to make detailed findings about the
circumstances in which people died, including calls made to the emergency services,
the transfer of information from the control room to the incident ground, the recording
of that information on its way to and at the bridgehead and the steps taken to rescue
those who were trapped. We are satisfied that all those who died in the building were
overcome by toxic gases produced by the fire and with expert assistance we have
been able to establish a reasonably accurate time of death in each case. We are
satisfied that all those whose bodies were damaged by the fire were already dead by
the time it reached them.
In a moment my fellow panel members, Ms Istephan and Mr Akbor, wish to add some
comments of their own. Before they do so, however, I should like to thank the Inquiry
team, without whom it would not have been possible to carry out an investigation of
this kind. It would be invidious to single out individual names for mention on this
occasion because everyone involved, whatever their particular task, has played an
essential part in enabling us to do our work. With their help we have followed up many
lines of inquiry, some of which led to surprising revelations, and have collected and
digested a huge number of documents and statements, not to mention hearing many
days of oral evidence. All those who have worked for the Inquiry over the years are
named in an appendix to the report.
I now invite Ms Istephan to say a few words.
Thouria Istephan:
Thank you, Sir Martin.
Before I joined the inquiry panel I spent nearly 30 years working as an architect. In
that role I developed a particular interest in health and safety, fire and accessibility
matters. Returning home from a holiday in June 2017, I flew over west London and
saw the burning tower in the early hours from the air. As for so many others, this was
a profound shock: first of course as a human response, but also as a professional who
had spent their career working to make buildings safe. Throughout this inquiry, we
have been determined to find out how such a disaster was possible - and what needs
to be done to save lives in the future.
As Sir Martin has just summarised, we have found many failings across a wide range
of institutions, organisations and individuals that spanned many years - which together
led to the terrible fire at Grenfell Tower. They include many failures of the construction
industry - my own sector - which is where I will focus my comments on today.
Since the fire, the Government has passed the Building Safety Act. The Act is welcome
but we need to go further. Our report identifies what we think is needed to make sure
that the legacy of Grenfell is real and brings about lasting and progressive change.
Our recommendations place new burdens and responsibilities on people and
organisations. I make no apologies for that: put simply, if you work in the construction
industry and you do not feel the weight of the responsibility you have for keeping
people safe - you are in the wrong job.
The change we need to bring about is partly about structures and regulations. Sir
Martin has set out the key points of what we have proposed, and the report explains
our recommendations in detail. But the necessary change is also one of culture and
behaviour. Change on this scale needs to be owned and led by those of us working in
the sector. It is not enough to pass an Act of Parliament and to sit back and think the
work is done. Without changes in behaviour - and a recognition that the needs of the
people who use our buildings must be placed at the centre of our work, the lessons of
Grenfell will not truly be learned in full.
One of the core themes of our report is technical incompetence of many of those
involved in the refurbishment project. As hundreds of other buildings are now known
to have similar cladding systems, it is clear that the problem of incompetence is
widespread. It follows that part of the change that is needed to the culture of the
industry is an ongoing commitment to the development of professional skills. If we are
not professionally curious we will not become technically competent. Again, this
change needs everybody in the construction industry to play their part in the
implementation of the Inquiry’s recommendations.
We must also keep at the very forefront of our minds our responsibilities towards those
who are most vulnerable. At Grenfell, a significant number of those who died were
children, had disabilities, or were vulnerable in other ways. The risks posed by a
particular building - and the right response to those risks - are always as diverse as
the people who live or work in it. That is why we recommend that the Government
thinks again about defining ‘higher-risk’ buildings solely by reference to their height. It
is why fire safety strategies must provide for the safety of all occupants - and it is why
a ‘stay put’ strategy will never be appropriate where there is a risk of fire spreading
over a building’s external walls. It is why we recommend that Government guidance
should be reviewed, so that the safety and resilience of a building is prioritised. And it
is why we stand by the Inquiry’s Phase 1 recommendation about the need for PEEPS
- personal emergency evacuation plans - for residents with mobility issues or other
impairments.
As an inquiry panel we have acted throughout with fairness, independence and
impartiality. That is what the law requires. At the same time, the losses so many people
have suffered and my involvement in this process have left a mark on me as a person
and a professional which will last far beyond this Inquiry. And although the inquiry is
now ending, we know that for many people their journey continues. We wish them
strength for the future.
I will now hand over to my colleague Ali.
Ali Akbor:
Thank you, Thouria.
My role as a panel member has been to listen to the evidence, to consider what I have
heard, and to work with Sir Martin and Thouria to agree findings and
recommendations.
Firstly, I would like to express my own heartfelt sympathy to all those whose lives have
been affected by this tragic fire. We know that an inquiry can feel like a very slow
process. What I can say is that we have been painstakingly thorough and that we
present our report to you with confidence in its veracity. Secondly, I would like to say
that I grew up in council housing. I was involved in creating social housing
organisations. I was chief executive of a housing association for twenty years. What I
can say is that working on the inquiry has had a profound impact on me both personally
and as a social housing professional.
In social housing we often say that we put our tenants at the heart of what we do. But
it is not enough just to pay lip service to that ideal. In our report we look at the
relationship between the Kensington and Chelsea Tenant Management Organisation
and its residents before the fire. We find that it was one of distrust, dislike, personal
antagonism and anger. Residents deserved to be treated with understanding and
respect. The TMO failed to do that.
We saw a similar failure to treat residents as people - and as individuals - in the
aftermath of the fire. Including in the way that those with religious, cultural or social
needs suffered discrimination as a result of RBKC’s failure to prepare properly for
emergencies. It was obvious to me from watching and listening to evidence being
given at the hearings that there were two different groups of people, those who lived
at Grenfell and those who worked for the TMO, RBKC and their agents.
In our report we set out how the Government’s focus on deregulation dominated the
department’s thinking such that even matters affecting the safety of life were ignored,
delayed or disregarded. The deregulation agenda had a parallel impact on the social
housing sector - particularly in terms of consumer standards and protection for tenants.
The effects of that can be seen in the many failings of the TMO which we set out in
our report - and which were not prevented or addressed by the regulatory system then
in place.
Parliament has now passed the Social Housing (Regulation) Act, which will enhance
the powers of the regulator in support of stronger consumer standards, and which
stresses the need for involvement and empowerment of tenants, and the
reintroduction of inspections of landlords. In my view, this was not a moment too soon.
Our report underlines why its full implementation is so important and so urgent.
I have focused so far on the TMO’s role as a social housing provider. The TMO also
played an important part in the refurbishment of Grenfell Tower in its role as the
project’s client. We have found that the TMO paid insufficient care in its choice of
architect and failed to pay enough attention to fire safety. I hope that our report acts
as a reminder to the clients of future building projects - including social housing
providers - that they have a responsibility to the users of their buildings to ensure that
safety is not sacrificed to the demands of speed and cost. Regulations should not be
treated as boxes to be ticked, but as a way of giving residents confidence that their
homes are safe.
Finally, I would like to echo something that Thouria has said. We cannot in a few words
here today do full justice to the totality of our report. What is needed is for those with
responsibility for building safety - in my sector as in Thouria’s - to read the report, to
reflect on it, and to treat Grenfell as a touchstone in all that they do in the future. That
is to act with professionalism, with competence, and to put people first.
I will now pass you back to Sir Martin. Thank you.
Sir Martin Moore-Bick:
We should remember that the Grenfell Tower fire was and remains an intensely
personal tragedy for all those who lived in and around the tower and above all for those
who died, their families and friends.
We invite you, therefore, to join us in remembering them while I read out their names:
Fathia Ahmed Elsanousi
Abufras Mohamed Ibrahim
Isra Ibrahim
Mohammed Amied (Saber) Neda
Hesham Rahman
Rania Ibrahim
Fethia Hassan
Hania Hassan
Marco Gottardi
Gloria Trevisan
Raymond Herbert (Moses) Bernard
Eslah Elgwahry
Mariem Elgwahry
Anthony Keith Disson
Bassem Choukair
Nadia Choucair
Mierna Choucair
Fatima Choucair
Zainab Choucair
Sirria Choucair
Hashim Kedir
Nura Jemal
Yahya Hashim
Firdaws Hashim
Yaqub Hashim
Abdulaziz El Wahabi
Faouzia El Wahabi
Yasin El Wahabi
Nur Huda El Wahabi
Mehdi El Wahabi
Ligaya Moore
Jessica Urbano Ramirez
Omar Belkadi
Farah Hamdan
Malak Belkadi
Leena Belkadi
Mary Mendy
Khadija Saye
Victoria King
Alexandra Atala
Mohamednur Tuccu
Amal Ahmedin
Amaya Tuccu -Ahmedin
Amna Mahmud Idris
Majorie Vital
Ernie Vital
Debbie Lamprell
Gary Maunders
Berkti Haftom
Biruk Haftom
Hamid Kani
Isaac Paulos
Sakina Afrasehabi
Fatemeh Afrasiabi
Vincent Chiejina
Khadija Khalloufi
Kamru Miah
Rabeya Begum
Mohammed Hamid
Mohammed Hanif
Husna Begum
Joseph Daniels
Sheila
Steven (Steve) Power
Zainab Deen
Jeremiah Deen
Mohammad Alhajali
Denis Anthony Peter Murphy
Ali Yawar Jafari
Abdeslam Sebbar
Logan Gomes
Pily Burton
Thank you all very much.