Grenfell Tower Fire Inquiry Maps Out Chain of Failures That Led to Disaster
A chain of failures by governments, “dishonest” companies, and a lack of fire service strategy or coordination for high-rise building fire response culminated in the 2017 Grenfell Tower fire disaster that killed 72 people, a new public inquiry report concluded.
The Grenfell Tower Inquiry’s 1,700-page report describes the course of events leading up to the fire, starting with 1990s regulations around the external walls of high-rise buildings and continuing through the disastrous 2016 refurbishment that added a cladding to the exterior of the building.
The cladding on the outside of the Grenfell Tower residential high-rise, located in West London was made of highly flammable polyethylene, and a fire on the fourth floor of the building rapidly spread up the sides of the building because of that coating. Many residents were trapped on the higher floors and could not escape.
“We conclude that the fire at Grenfell Tower was the culmination of decades of failure by central government and other bodies in positions of responsibility in the construction industry to look carefully into the danger of incorporating combustible materials into the external walls of high-rise residential buildings and to act on the information available to them,” the report explained.
The inquiry found that manufacturers of the cladding and insulation were systematically dishonest about their products, and it claimed that the cladding manufacturer deliberately concealed the true extent of the danger of using its product, including by manipulating testing processes and misrepresenting test data, the BBC reported. After multiple large-scale tests, environmental reports, and other analysis about this type of cladding, the UK government was “well aware of those risks, but failed to act on what it knew,” the report said.
Product standards compliance organizations failed to hold manufacturers and installers to high standards and did not “adhere robustly to the system of checks it had put in place,” the report added. In addition, the Local Authority Building Control was vulnerable to manipulation about product safety because its processes were not rigorously implemented to perform adequate due diligence.
The Tenant Management Organisation (TMO) also had a troubled relationship with the residents of Grenfell Tower, culminating in ongoing issues in governance, customer service, staff attitudes, and poor repairs service. Residents did not trust the TMO, and many occupants viewed the organization as a bullying overlord that failed to take their concerns seriously, the report explained. “The result was a toxic atmosphere fuelled by mistrust on both sides,” it said.
“However irritating and inconvenient it may at times have found the complaints and demands of some of the residents of Grenfell Tower, 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,” the report concluded.
TMO also had a “persistent indifference to fire safety, particularly the safety of vulnerable people,” the report said. An independent fire safety consultant recommended that the group prepare a fire safety strategy in 2009, but a strategy had not been finally approved by the time of the fire in 2017. The emergency plan for Grenfell Tower was out of date and incomplete, and it did not reflect the changes from the 2016 refurbishment by the time the fire occurred.
In addition, “there was no adequate system for ensuring that defects identified in fire risk assessments were remedied effectively and in good time,” the inquiry found. “The TMO developed a huge backlog of remedial work that it never managed to clear, a situation that was aggravated by the failure of its senior management to treat defects with the seriousness they deserved. Indeed, on one occasion senior management intervened to reduce the importance attached to the implementation of remedial measures. The demands of managing fire safety were viewed by the TMO as an inconvenience rather than an essential aspect of its duty to manage its property carefully.”
"I want to say very clearly on behalf of the country, you've been let down so badly. Before, during and in the aftermath of this tragedy"
— BBC Politics (@BBCPolitics) September 4, 2024
PM Keir Starmer gives a statement on the final Grenfell inquiry report
Follow live https://t.co/Lclw3iSxYl pic.twitter.com/EBPgQvfKji
The inquiry also outlined failures in the London Fire Brigade’s (LFB’s) training and its lack of strategy to evacuate high-rise buildings. The report noted that senior officers in the LFB were complacent about the brigade’s operational efficiency and “lacked the management skills to recognise the problems or the will to correct them.”
“The LFB failed to ensure that the knowledge of the dangers presented by the increasing use of combustible materials, in particular the risk of external fire spread and the resulting loss of compartmentation, held by some specialist officers was shared with the wider organization and reflected in training, operational policies and procedures,” the report continued. “Firefighters were not given proper training or guidance on how to carry out inspections of complex buildings and there were no effective arrangements for sharing information about risks posed by particular buildings. Internal recommendations for improving the inspection of high-rise residential buildings were not implemented.”
Additionally, the LFB failed to recognize that a fire in a high-rise residential building would result in a large volume of calls seeking help, both from within and outside the building. During the Grenfell Tower fire, people in the control room and on the ground were forced to improvise to handle the large amount of information they received.
“The senior officers responsible for the control room understood the need to give priority to training staff in handling fire survival guidance calls, but in the years between 2010 and 2017 no structured or regular refresher training in handling fire survival guidance calls was designed or delivered to control room staff,” the inquiry found.
