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The Grenfell fire was caused by the “systematic dishonesty” of construction companies that manufactured cladding for the tower block’s refurbishment, a seven-year public inquiry has concluded.
Sir Martin Moore-Bick, the inquiry chairman, also placed blame for the fatal inferno on “decades of failure” by government ministers and officials who ignored a series of warnings over the risk of cladding fires.
He said regulators had put “commercial interests” above building safety and had been “complicit” in allowing manufacturers to “manipulate” fire-testing data.
The seven-volume report of more than a million words exposed multiple failings that led to the fire in June 2017 in which 72 people died, just a year after the 24-storey tower block was refurbished.
Also criticised heavily were the London Fire Brigade, the architects involved in the refurbishment and the local authority.
The report will be scrutinised by police and the Crown Prosecution Service, with grieving relatives and survivors demanding that those responsible and identified in the report be charged and brought to justice.
The Metropolitan Police said that it would take 12 to 18 months to examine the report “line by line” alongside the evidence from the criminal investigation.
A huge fire engulfs the 24 story Grenfell Tower in the early hours of June 14, 2017, in London, England. Photo / Getty images
The report set out to establish: “How was it possible in 21st-century London for a reinforced concrete building, itself structurally impervious to fire, to be turned into a death trap that would enable fire to sweep through it in an uncontrollable way in a matter of a few hours despite what were thought to be effective regulations designed to prevent such an event.”
It said there was “no simple answer”, adding “but in this report we identify the many failings of a wide range of institutions, entities and individuals over many years that together brought about that situation”.
Victims are furious that it could be another two to three years – and 10 years after the fire – before any cases get to court amid claims the public inquiry has delayed the criminal justice system.
Grenfell Next of Kin, a group which represents the families of almost half of those killed, said: “The Grenfell Tower Inquiry report is hard-hitting and the chairman does not mince his words, but the sad truth for us the families of the deceased is will there be manslaughter charges?”
Sir Martin, a former Court of Appeal judge, exposed the cosy relationship between regulators and building companies that had allowed highly combustible materials to be installed on high-rise blocks.
In his report, he said: “One very significant reason why Grenfell Tower came to be clad in combustible materials was systematic dishonesty on the part of those who made and sold the rain-screen cladding panels and insulation products.
“They engaged in deliberate and sustained strategies to manipulate the testing processes, misrepresent test data and mislead the market.”
He said that in the case of the core insulation product used on the tower – Celotex RS5000 – the Building Research Establishment (BRE), one of the chief regulators at the time, “was complicit in that strategy”.
Arconic, which made the aluminium composite material (ACM) cladding used to cover the tower, had pursued a “deliberate strategy” to continue selling its Reynobond 55 PE cladding in the UK “based on a statement about its fire performance that it knew to be false”.
The inquiry concluded that Arconic, a France-based company, had been “determined to exploit what it saw as weak regulatory regimes in certain countries (including the UK) to sell Reynobond 55 PE in cassette form, including for use on residential buildings”.
Kingspan, an Irish conglomerate which provided 5% of the insulation to Grenfell, had “knowingly created a false market in insulation” for use on buildings over 18 metres in height. Sir Martin said Kingspan had “cynically exploited” the construction industry’s ignorance over what was safe to use on high-rise buildings.
Sir Martin found the “choice of combustible materials for the cladding of Grenfell Tower resulted from a series of errors caused by the incompetence of the organisations and individuals involved in the refurbishment”.
He said Studio E, the architecture firm which has since gone bust, Harley Facades, the cladding subcontractor, as well as Rydon, the main contractors, “all took a casual approach” to fire safety.
Studio E, he said, had “demonstrated a cavalier attitude to the regulations affecting fire safety” while Rydon and Harley “relied on their previous experience rather than on any technical analysis or expertise”.
Studio E’s failure to warn against the use of ACM cladding had “represented a failure to act in accordance with the standard of a reasonably competent architect … and therefore bears a very significant degree of responsibility for the disaster”.
In a withering assessment of the role played by government and regulators in allowing dangerous cladding on Grenfell and thousands of tower blocks around the UK, the inquiry said: “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 concluded that previous governments had been aware of the dangers posed by combustible cladding for almost 20 years but “failed to heed” myriad warnings including a parliamentary select committee report in 1999.
The Department for Communities and Local Government had also received “numerous warnings about the risks” posed by the cladding in the five years between 2012 and 2017 but ignored those too.
Among individuals singled out for criticism was Carl Stokes, a former firefighter who had been employed as the sole fire assessor in the Royal Borough of Kensington and Chelsea (RBKC).
He was responsible for safety in 650 properties, a figure Sir Martin said was ludicrous. The judge also found he had falsified some qualifications and lied about his experience when applying for the job.
The report said that “the fire safety training he had completed did not entitle him to invent qualifications and use them as he did” to secure the job.
The inquiry also castigated his boss at the Tenant Management Organisation (TMO), which managed Grenfell on behalf of the council. Robert Black, the TMO’s chief executive, did not regard “fire safety as a high priority”, concluded the report.
The then government and the local authority were also condemned for their response in the aftermath of the Grenfell fire which was branded “muddled, slow, indecisive and piecemeal”.
It singled out Nicholas Holgate, the council’s chief executive, describing him as “not well suited to dealing with the crisis that was unfolding in front of him”. It added: “He was reluctant to take advice from those with greater experience and was unduly concerned for RBKC’s reputation.”
It has been reported that Gene Murgah, Kingspan’s chief executive, made £26 million ($55m), including from a £3m ($6.4m) block of shares sold shortly before damning evidence emerged at the Grenfell Inquiry
He bought a £6.3m ($13.4m) seafront mansion in Dublin a year after the disaster.
Meanwhile Robert Bond, a director at Rydon, the construction firm which conducted the Grenfell refurbishment, reportedly lives in a £3m mansion on a private estate in southeast London and drives an Aston Martin.
Sir Martin, who met with survivors and the bereaved, told them: “The deaths were all avoidable.”
In a statement, a Grenfell Next of Kin spokesman said: “All those mentioned in the report have blood on their hands but it fails to identify who can be charged for manslaughter and that is what justice means for us.”
Nazanin Aghlani, whose mother and aunt died, said: “It was evident that there were multiple failures on the night. We didn’t ask for a public inquiry. What we wanted was prosecutions and this doesn’t bring any closure. Unless there are manslaughter prosecutions with people going to prison there’s no closure.”
Stuart Cundy, Deputy Assistant Commissioner of the Met Police, said: “Our police investigation is independent of the public inquiry. It operates under a different legal framework and so we cannot simply use the report’s findings as evidence to bring charges.
“To secure justice for those who died and all those affected by the fire we must examine the report – line by line – alongside the evidence from the criminal investigation. As I said previously, this will take us at least 12-18 months.
“This will lead to the strongest possible evidence being presented to the Crown Prosecution Service so they can make charging decisions.
“I can’t pretend to imagine the impact of such a long police investigation on the bereaved and survivors, but we have one chance to get our investigation right.
“We will be thorough and diligent in our investigation while moving as swiftly as possible.”
In total, the report made 58 recommendations, including tightening up building regulations and improving government oversight of fire safety.
It called on the Government to “immediately” establish a Fire and Rescue Service college as there is “currently no central body that is equipped to provide education and training ... to nationally approved standards”.
It highlighted how standards of basic firefighter training were inadequate, with fire service personnel “unable to distinguish between different types of hydrant”.
“That is a clear indication of a need for better training,” the report stated.
While recognising that “firefighters must be allowed to exercise discretion in how best to carry out their instructions”, the report’s authors said they were “struck by the number of times crews dispatched to the highest floors failed to reach their destinations because they decided to help people they encountered on the stairs on their way up”.
It makes it clear it is impossible to say whether residents on higher floors could have been rescued had the firefighters carried out their original instructions, but said the National Fire Chiefs Council should consider whether, and in what circumstances, firefighters should be “discouraged” from departing from their instructions on their own initiative. Training on how to respond in such situations should be given, it said.
The inquiry to date has cost more than £170m ($361m).
The Grenfell Tower Report in detail
Across more than a million words, Sir Martin Moore-Bick has sought to forensically unpick the decisions that led to the worst residential fire in Britain since the Second World War.
In this final inquiry report, he points the finger of blame not just at cladding manufacturers and the organisations supposed to regulate them, but also officialdom, from local council officers to the highest offices of state.
Who’s who in the web of blame - The companies, departments and people who have accused one another
Royal Borough of Kensington and Chelsea
Owner of Grenfell Tower who managed the building and commissioned the 2015-16 refurbishment
The final report found that there were “many opportunities” for Whitehall to “identify the risks posed by the use of combustible cladding panels and insulation, particularly to high-rise buildings, and to take action in relation to them”.
It highlighted a warning issued by a parliamentary select committee as long ago as 1999 that “it should not take a serious fire in which people were killed” to tackle the dangers posed by cladding.
The Department for Communities and Local Government (DCLG) also “failed to pay due regard to the striking results of a large-scale test in 2001 involving aluminium composite panels with unmodified polyethylene cores, which burned violently … It failed even to publish the results of the test”.
The department also received “numerous warnings about the risks” posed by the cladding in a five-year period between 2012 and 2017 but ignored those too.
The inquiry concluded that by 2016 the government was well aware that Grenfell-style cladding systems were being “routinely used on high-rise buildings in breach” of official safety guidance.
The report said that DCLG was “poorly run”, not least because the official with “day-to-day responsibility for the buildings regulations … was allowed too much freedom of action without adequate oversight”.
The report went on: “He failed to bring to the attention of more senior officials the serious risks of which he had become aware, and they in turn failed to supervise him properly or satisfy themselves that his response to matters affecting the safety of people’s lives was appropriate. It was a serious failure to allow such an important area of activity to remain in the hands of one relatively junior official.”
The official was Brian Martin, who is now reportedly a senior independent fire adviser.
DCLG was also branded “complacent” on fire safety. A coroner’s recommendation following a fire at Lakanal House in south London in 2009 was “not treated with any sense of urgency”.
The Building Research Establishment
The BRE – the government body in charge of fire safety tests – was “marred by unprofessional conduct, inadequate practices, a lack of oversight, poor reporting and a lack of scientific rigour”, the report found.
The BRE had failed to draw attention to the large-scale testing of an ACM cladding system in 2001 which showed the dangers it posed.
The inquiry also found that the BRE’s record-keeping “exposed it to the risk of manipulation by unscrupulous product manufacturers”.
BRE staff advised Celotex and Kingspan, which also made the insulation for Grenfell, on how to pass safety tests, “thereby compromising its integrity and independence”.
Royal Borough of Kensington and Chelsea (RBKC) and The Tenant Management Organisation (TMO)
The relationship between the Grenfell residents and the TMO which managed the tower block was so bad there was a “toxic atmosphere fuelled by mistrust on both sides”.
The report found: “The TMO lost sight of the fact that the residents were people who depended on it for a safe and decent home and the privacy and dignity that a home should provide.”
Residents found the TMO to be an “uncaring and bullying overlord that belittled and marginalised them, regarded them as a nuisance, or worse, and failed to take their concerns seriously”.
RBKC, which owned Grenfell, showed a “persistent indifference to fire safety, particularly the safety of vulnerable people” along with the management organisation that ran the building.
RBKC’s oversight of the TMO “was weak”, especially when it came to ensuring fire safety, said the report.
RBKC, for example, ignored a “highly critical review of fire safety” carried out for the TMO as far back as 2009.
The inquiry highlighted the behaviour of Robert Black, the TMO’s chief executive, who had an “entrenched reluctance… to inform the [TMO] board and RBKC’s scrutiny committees of matters that affected fire safety”.
That failure was all the more serious because there were “chronic and systemic failings in the TMO’s management of fire safety of which the board should have been made aware”.
Black, concluded the inquiry, had “consistently failed” to inform either the TMO board or the council of London Fire Brigade’s concerns over a fire safety order. “Clearly,” concluded the report, he did not regard “fire safety as a high priority”.
The council had failed to put in place a fire safety strategy first recommended in 2009 by the time the inferno took place in 2017.
The report said: “The TMO’s only fire assessor for its entire estate, Carl Stokes, was allowed to drift into that role without any formal selection or procurement process.”
Stokes, a former firefighter, was the sole fire risk assessor for seven years, with responsibility for 650 properties until his contract was terminated in November 2017.
However, the report stated: “The fire safety training he had completed did not entitle him to invent qualifications and use them as he did” in getting the job.
The report found he had also lied about how much experience he had.
In his application for the job, Stokes submitted a statement and included a series of seeming qualifications after his name. It read: “Mr C Stokes: AClArb, FPA Dip FP (Europe), Fire Eng (FPA), NEBOSH, FIA BS 5839 System Designer, Competent Engineer BS 5266, IFE Assessor/ Auditor (FSO). 19 years Fire Safety experience with local Fire Authority, in enforcement and auditing roles, 3 years as an independent fire risk assessor. Member of the construction industry CPD certification Service. Professional Indemnity insurance cover provided by Hiscox. Enhanced CRB checked.”
However, Stokes was “not a member of any professional bodies”. Superiors at TMO were aware of this.
The report said: “He had misrepresented his experience and qualifications (some of which he had invented) and was ill-qualified to carry out risk assessments on buildings of the size and complexity of Grenfell Tower, let alone to hold the entire TMO portfolio.”
The report found Stokes did not carry out proper inspections of flat entrance doors which should have been self-closing. An inspection after the fire found 77 out of 120 self-closing devices on doors were either “missing or broken”. Stokes in his inspection in 2014 did not find any.
LFB had expressed concerns “about his competence” but the TMO “continued to rely uncritically on him, a situation which made the danger more acute in the absence of any arra]ngements for assessing the quality of his work”.
Problems with Grenfell included self-closing devices on flat doors which did not work and the absence of an evacuation plan for the tower.
London Fire Brigade
In withering criticism, the inquiry found the LFB’s “shortcomings in its ability to fight fires in high rise buildings” were a result of “a chronic lack of effective management and leadership”.
LFB had failed to learn the lessons of the Lakanal House Fire in 2009, in which compartmentalisation had failed to contain the fire that killed six people.
Its senior officers, including Dany Cotton, who was commissioner at the time of the Grenfell fire, “were complacent about the operational efficiency of the brigade”.
It said the fire brigade’s then leadership had been too reliant on building regulations.
After the Lakanal fire, senior officers had not “appeared to have thought that firefighters needed to be trained to recognise and deal with the consequences”.
The report said: “It appears that no one within the LFB gave any serious thought to the potential limitations of the ‘stay put’ strategy either before or after the Lakanal House fire.”
Response to the disaster
The response of the government and RKBC to the fire in the first week after it was “muddled, slow, indecisive and piecemeal,” the inquiry found.
“RBKC’s systems and leadership were wholly inadequate to the task of handling an incident of such magnitude and gravity, involving as it did, mass homelessness and mass fatalities. The resilience machinery in London and within the central government was not flexible enough and took too long to move into action.”
It singled out Nicholas Holgate, the council’s chief executive, for criticism.
Holgate “was not capable of taking effective control of the situation and mobilising support of the right kind without delay”.
“He had no clear plan and did not receive all the information he needed.
“He was not well suited to dealing with the crisis that was unfolding in front of him and lacked a strong group of officers to whom he could delegate responsibility… He was reluctant to take advice from those with greater experience and was unduly concerned for RBKC’s reputation.”
The Testing and Marketing of Building Products
Grenfell Tower came to be clad in combustible materials owing to the “systematic dishonesty” of those who manufactured and sold them, the report found.
Sir Martin Moore-Bick said of the companies: “They engaged in deliberate and sustained strategies to manipulate the testing process, misrepresent test data and mislead the market.”
He added that the Building Research Establishment (BRE) was “complicit” in that strategy, in the case of the use of Celotex RS5000, the principal insulation product.
The report also criticised the British Board of Agrement, a commercial organisation that certifies the compliance of products, and the Local Authority Building Control for failing to ensure that the statements in their product certificates were “accurate and based on test evidence”.
UKAS, the organisation in charge of overseeing certification bodies, also failed to apply proper standards of monitoring and supervision.
Arconic
Arconic manufactured and sold the Reynobond 55 PE rainscreen panels used to clad the external wall of the tower.
The report found that “from 2005 until after the Grenfell Tower fire Arconic deliberately concealed from the market the true extent of the danger of using Reynobond 55 PE in cassette form, particularly on high-rise buildings.”
The panels used an ACM product made of two thin sheets of aluminium with a polyethylene core to stiffen it.
It was “extremely dangerous” when used in cassette form because polyethylene burns fiercely, the report said.
From early 2005 Arconic had test data showing that in its cassette form, the product reacted to fire in a “very dangerous way”, meaning it could not be classified in accordance with European standards.
However, in its marketing, Arconic did not distinguish the cassette and other forms.
Despite being aware of serious concerns in the construction industry about the safety of ACM panels, the firm was “determined to exploit what it saw as weak regulatory regimes in certain countries (including the UK) to sell Reynobond 55 PE in cassette form, including for use on residential buildings”.
The company did not consider withdrawing the product in favour of fire-resistant versions, which were available, despite cladding fires in Dubai in 2012 and 2013.
The judge said the company instead allowed customers in the UK to keep buying the unmodified highly combustible product while “giving them to understand” that it would inform them if it was unsuitable for the use they intended to put it to.
In reality, the company had no intention of raising the alarm, the report found.
After more testing in 2013, Arconic decided that Reynobond 55 PE would be certified Class E only but it did not pass this information on to customers in the UK or the BBA.
Sir Martin said: “This reflected a deliberate strategy to continue selling Reynobond 55PE in the UK based on a statement about its fire performance that it knew to be false.”
The firm also failed to inform the BBA when the French testing organisation CSTB classified the panels in cassette form as Class E in 2014.
The cladding performed much worse in cassette than in riveted form, but it persuaded the BBA to issue a certificate that drew no distinction.
Celotex
The firm which manufactured the combustible RS5000 polyisocyanurate foam insulation, which covered the majority of the tower, “embarked on a dishonest scheme to mislead its customers and the wider market” in an attempt to break into the insulation market for high-rise buildings, the report found.
Celotex conducted a fire test of the product that included two sets of fire-resistant boards “placed in critical positions to ensure that it passed”.
It did this with the complicity of the British Board of Agrément, Sir Martin concluded.
BRE then provided a report that included no reference to the magnesium fire boards, rendering it “materially incomplete and misleading”.
RS5000 was then marketed by Celotex as acceptable for use in buildings above 18 metres high.
The firm “deliberately” tucked away in the small print of its marketing literature the fact that the fire test had been designed to test a whole system, rather than an individual component product.
The judge described the marketing of RS5000, previously known as FR5000, as “false and misleading”.
“Celotex presented RS5000 to Harley as suitable and safe for use on Grenfell Tower, although it knew that was not the case.
A firm which provided roughly 5% of the insulation at Grenfell.
The report found that for years the firm had “knowingly created a false market in insulation” for use on buildings over 18 metres in height.
It did this by claiming that its K15 product had been part of a successful system test.
“That was a false claim” because the BS8414 test is a method for testing complete wall systems only.
The judge found that “tests performed in 2007 and 2008 on systems incorporating the then current form of K15 were disastrous, but Kingspan did not withdraw the product from the market, despite its own concerns about its fire performance”.
He also found that the firm had concealed from the BBA the fact that it had changed its product from that which had been certified 2008.
The judge said the BBA’s certificate used forms of words suggested by Kingspan and drawn from its own marketing literature in the safety certificate.
Ultimately, three important statements about the product’s fire performance were untrue, Sir Martin said.
Kingspan also relied for many years on a certificate from LABC which contained false statements about K15.
In continued testing of K15, Kingspan did not use a realistic version of the product it was marketing, but used “modified or trial versions”.
Kingspan “cynically exploited” the industry’s lack of detailed knowledge about the type of test it had submitted the product to and “relied on the fact that an unsuspecting market was very likely to rely on its own claims about the product”, the report found.
British Board of Agrément (BBA)
The report found that: “Its certificates were accepted in the industry largely without question but its procedures were neither wholly independent nor rigorous and they were not always rigorously applied.”
Sir Martin said the dishonest strategies of Arconic and Kingspan succeeded in a large measure owing to the incompetence of the BBA.
The organisation allowed the need to attract and retain customers to weaken the independence of its investigations.
Misleading certificates were the result.
Indeed, Sir Martin said the organisation “accepted for inclusion in certificates forms of wording proposed by manufacturers that were wrong and misleading”.
In the case of Arconic, the manufacturer repeatedly failed to provide new information to the BBA about its product, but BBA still re-issued certificates.
In relation to Kingspan, the BBA “effectively allowed the contents of the certificates relating to Kingspan K15 to be dictated by Kingspan itself”.
An organisation formed by local authority building control departments, it issues certificates verifying the compliance of construction products and systems.
Sir Martin said the LABC must take its share of the blame for the acceptance by the market of Celotex RS5000 and Kingspan K15 for use on buildings over 18 metres in height.
“There was a complete failure on the part of LABC over a number of years to ensure that the certificates it issued in respect of them were technically accurate,” he said.
Assessment of products was given to building control officers who did not have sufficient knowledge and experience.
As with BBA, LABC was “willing to accommodate the customer at the expense of those who relied on the certificates”.
“As a result, the LABC was also the victim of dishonest behaviour on the part of unscrupulous manufacturers.”
The National House Building Council, which employed a large number of approved inspectors, wielded considerable influence on the industry, the report said.
“However, it failed to ensure that its building control function remained essentially regulatory and free of commercial pressures.
“It was unwilling to upset its own customers and the wider construction industry by revealing the scale of the use of combustible insulation in the external walls of high-rise buildings, contrary to the statutory guidance.
“We have concluded that the conflict between the regulatory function of building control and the pressures of commercial interests prevents a system of that kind from effectively serving the public interest.” the report concluded.
The United Kingdom Accreditation Service
This body’s assessments were “lacking in rigour and comprehensiveness”, Sir Martin found.
“The process relied too much on the candour and co-operation of the organisations being assessed and too much was left to trust.”
The report also noted that its powers to take action were “surprisingly limited” and it had no powers of enforcement.
The refurbishment process: Studio E, Rydon and others
The Tenant Management Organisation manipulated the procurement process to avoid having to put the contract for architectural services out to public tender, the report found.
The organisation was advised by its lawyers that it would be improper to appoint construction firm Rydon without a competitive process, but the deal went ahead regardless after the company promised that it would reduce its prices.
“The choice of combustible materials for the cladding for Grenfell Tower resulted from a series of errors caused by the incompetence of the organisations and individuals involved in the refurbishment,” Sir Martin wrote.
He pointed to Studio E, the architects, Harley Facades, the cladding subcontractor, as well as Rydon, saying “all took a casual approach”.
“Each failed to identify their own responsibilities for important aspects of the design and in each case assumed that someone else was responsible for matters affecting fire safety,” the report found.
“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.”
Sir Martin said: “Studio E demonstrated a cavalier attitude to the regulations affecting fire safety and Rydon and Harley relied on their previous experience rather than on any technical analysis or expertise.”
For its part, the Royal Borough of Kensington and Chelsea did not properly scrutinise the design or choice of materials and failed to satisfy itself that building regulations would be met.
Exova, a fire engineering firm, was commissioned to prepare a fire safety strategy but never completed the task.
Sir Martin said that Studio E’s failure to warn TMO against the use of ACM cladding “represented a failure to act in accordance with the standard of a reasonably competent architect”.
It also failed to recognise that Celotex insulation was combustible and not suitable for use on highrise buildings.
“Studio E therefore bears a very significant degree of responsibility for the disaster,” the report states.
As for Exova, he concludes that the firm’s attitude was “wholly inconsistent with the careful approach to matters affecting the safety of life to be expected of a reasonably competent fire engineer”.
Rydon, too, is criticised for giving “inadequate thought to fire safety”.
Harley Facades was also criticised for not concerning itself “sufficiently with fire safety at any stage of the refurbishment”.
