Grenfell Tower Inquiry phase 2 report: Scottish Government response

3: The Grenfell Inquiry Phase 2 Report

Phase 2 of the Inquiry focused on the causes of the events leading up to the fire, including how Grenfell Tower came to be in a condition which allowed the fire to spread in the way identified by Phase 1. Focusing on the physical condition of the Tower it considered how the fire spread was unexpected, and the reasons and causes.

The Phase 2 Report described this as follows:

Volume 1, paragraph 1.3: “In Phase 2 we have set out to answer the question that has been at the forefront of many people’s minds: 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 just such an event? There is no simple answer to that question, 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.”

The Phase 2 Report makes fifty-eight recommendations mostly directed to the UK Government, but also to the National Fire Chiefs Council, HM Inspectorate of Constabulary and Fire and Rescue Services, the Police, the London Fire Brigade, and local authorities. Fifty-six are new, whilst two have been brought back from the Phase 1 Report, recommending further attention. It is clear to see the rationale for recommending action and to understand the specific problems being addressed.

There is nothing in the report that is surprising to anyone who has followed the work of the Inquiry over its lifetime. The recommendations are straightforward and in general not contentious.

This section of our report sets out in a highly summarised manner some of the key findings of the Inquiry. The Scottish Government has not sought to interpret these findings, but it is important to note them in preparing our response.

The Inquiry clearly sets out the rationale behind referring to the dishonesty of those companies involved in manufacturing the products that were used on the external walls of the building. The failures and poor behaviours of those involved in the ownership and management of Grenfell Tower have been set out clearly. The failures of those organisations charged with upholding standards in the construction industry are also clearly set out. The failures in government to address building safety matters was also openly addressed by the Inquiry.

The report is set out in seven volumes and 113 chapters, 14 parts and 1,700 pages. It provides the path to disaster, a range of matters that together have led to the tragedy. The evidence in this part relates to the historic development of fire testing, building regulation and the role of government and other parties.

The report considers matters such as the Investigation of real fires report, which was a contract let by the UK Government to the Building Research Establishment (BRE). Criticisms were made of reports on previous cladding fires and the contract through which this was undertaken. There was a lack of action on these reports, and they were not obviously connected to the development of regulations and guidance.

The statutory guidance in England, Approved Document B, on complying with functional requirement B4(1) of the Building Regulations was found to be defective. The use of Class 0 as a standard of fire performance for products to be used on the external wall of tall buildings was inappropriate. The European classifications based on the single burning item test were of similarly limited assistance.

The Inquiry set out the limitations of the large-scale fire test (BS 8414) and performance criteria set out in the Classification Report (BR 135). Approved Document B failed to make it clear that the results of the BS 8414 test always had to be analysed in conjunction with all other available information to understand the way in which the wall was likely to behave when exposed to the flames and heat of a fully developed compartment fire. The method adopted in BR 135 for assessing compliance was too simplistic. It provided a simple pass or fail result when the results of the test required a degree of interpretation beyond the competence of most in the industry.

The Inquiry determined that the government had not resourced life safety policy areas appropriately, with one civil servant having too much responsibility for fire safety regulations, a single point of failure. The failure of government to understand what products were being used in the construction of high-rise buildings was noted. Where feedback was provided by those in industry it was not acted upon.

The report also sets out the impact of deregulation on taking forward work to update regulations and guidance on fire safety, particularly after 2010. There were concerns on any action that would increase the regulatory burden.

The report addresses the testing and marketing of products. It sets out the actions of Arconic, Kingspan and Celotex the manufacturers of the materials used to over clad Grenfell Tower. The actions of the manufacturing companies in getting products to market were set out, with dishonesty at the centre of creating and maintaining the high-rise market exposed. The actions of companies were determined to be dishonest and those responsible for testing and certification had been manipulated and not acted in a diligent manner. Commercial interests of those involved in fire testing and certification was compromised.

KCTMO had, as the Inquiry described, a troubled relationship with its residents for years before the fire. The Royal Borough of Kensington and Chelsea (RBKC) and the KCTMO were jointly responsible for the management of fire safety at Grenfell Tower.

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. They were not familiar with or did not understand the relevant provisions of the Building Regulations, Approved Document B, or industry guidance.

The Inquiry determined that London Fire Brigade (LFB) should have learnt from the Lakanal House fire in July 2009, particularly in its ability to fight fires in high-rise buildings.