The Grenfell Tower fire of June 14, 2017, which killed 72 people
June 14, 2017: A major fire broke out in Grenfell Tower, a 24-storey residential tower block in North Kensington, London which caused the deaths of 72 of the 293 people believed to be in the tower that night.
June 15: Prime Minister Theresa May announced an inquiry into the causes of the fire. In a statement to Parliament on June 22, she vowed: ‘No stone will be left unturned by this Inquiry.’
June 29: Mrs May revealed that Sir Martin Moore-Bick, a retired judge, would lead the public inquiry.
PHASE ONE: The events on the night of the fire
June 4, 2018: Evidential hearings began, with the first week seeing open statements on behalf of the key organisations and the presentation of reports by key expert witnesses.
The appointed expert witnesses were:
- Dr Barbara Lane, a fire safety engineer from Arup
- Colin Todd, a fire safety consultant from CS Todd & Associates
- Professor David Purser, from Hartford Environmental Research
- Professor Edwin Galea, Professor of Mathematical Modelling at the University of Greenwich
- Dr Ivan Stoianov, Senior Lecturer in Water Systems Engineering at Imperial College London
- Dr J. Duncan Glover, from Failure Electrical
- Professor José L. Torero, Director of the Center for Disaster Resilience, University of Maryland, USA
- Professor Luke Bisby, Professor of Fire and Structures at the University of Edinburgh
- Professor Niamh Nic Daeid, from the Centre for Anatomy and Human Identification, University of Dundee
- Rodney Hancox, Director, Gas Distribution Solutions
- Steve McGuirk, former Chief Fire Officer of Greater Manchester, Cheshire and South Yorkshire, former President of the Chief Fire Officers Association, and former Lead Adviser to the Local Government Association
June 25 to October 2: Evidence from the firefighters and fire officers was heard.
Watch Manager Michael Dowden, the initial incident commander, admitted that he had been unsure how to respond when the fire began climbing up the side of the building.
Several firefighters reported being in life-threatening situations and experiencing trauma after being unable to rescue residents.
Other issues discussed included communications problems, the sheer amount of smoke, the stay put policy that was eventually abandoned, equipment shortages, and missing fire safety features in the building such as floor plans.
September 27: Dany Cotton, LFB’s Commissioner, said the disaster was as unexpected as ‘a space shuttle landing on The Shard.’ She also said that ‘I wouldn’t change anything we did on the night.’
October 2019: PHASE ONE REPORT
Sir Martin’s 1,000-page Phase One report concluded that systemic failures by LFB caused a greater number of deaths in the tower fire.
The report also found that fire chiefs’ slavish adherence to the controversial ‘stay put’ policy prevented residents from escaping.
Its key findings included:
Cause of blaze: It started due to an electrical fault in a fridge-freezer in flat 16 on the fourth floor. Flat owner Behailu Kebede will be absolved of any blame.
More than 200 survivors and bereaved families are suing Whirlpool, which supplied the Hotpoint model in the flat.
Brigade training: The LFB’s preparation and planning for such a fire was ‘gravely inadequate’. Experienced incident commanders had ‘no training’ on the dangers of combustible cladding or on how to evacuate a high-rise block.
At the scene: Firefighters displayed ‘extraordinary bravery’ but incident commanders failed to recognise that a full evacuation may have been necessary.
If the decision to evacuate had been made it would have ‘resulted in fewer fatalities’. Crucial information was not shared by senior officers.
Control room: There were ‘shortcomings in practice, policy and training’. Call handlers did not always obtain the necessary information and were unaware of when to tell residents to evacuate.
Commissioner: The report criticised the LFB’s commissioner for her ‘remarkable insensitivity’ after she told a hearing in September 2018 she would change nothing about its response to the fire.
Inferno’s spread: The ‘principle reason’ that the flames spread so quickly up the tower block was due to the rain screen panels which ‘acted as a source of fuel’.
The insulation boards behind the cladding panels also accelerated the fire’s spread. These features were added during a refurbishment several months before the fire.
Building design: The failures of the building’s safety design were ‘rapid’. Many lobbies filled with fire 26 minutes after it started.
But Sir Martin said stairs were ‘not absolutely impassable’ over an hour into it.
Regulations: The tower’s external walls failed to comply with building regulations. There is ‘compelling evidence’ the walls did not ‘accurately resist the spread of fire’ but ‘actively promoted it’.
December 6: Dany Cotton announced her early retirement effective from December 31 after 32 years of service.
PHASE TWO: The circumstances and causes of the fire
January 28, 2020: The second phase of the inquiry opened with statements from lawyers for:
- Studio E, the architects of the 2015-16 refurbishment
- Rydon and Harley Façades, the buildings
- Celotex, who had made the combustible insulation
- Arconic, who had supplied the ACM panels
Lawyers for Rydon introduced emails that showed that Celotex knew that their combustible insulation product was not safe to use with ACM panels as a suitable fire barrier was not available.
They also produced internal emails from Arconic from 2011 showing that the fire-rating of their Reynobond PE (polyester filled) panels had dropped to class E from class B and so were ‘unsuitable for use on building façades’ in Europe.
The combustible cladding panels made by Arconic, which contained the flammable polyethylene core, were chosen as part of an attempt to cut £454,000 from the budget.
The architect, builders and fire engineer who worked on the refurbishment knew the cladding system would fail in the event of a fire more than two years before the blaze, in conditions where the fire flamed through windows.
The lawyers for Celotex introduced an email thread where Daniel Anketell-Jones of Rydon discusses the need for a fire stop in the cavity and this was copied and discussed by the other organisations involved.
After the companies’ opening statements were read, Richard Millett criticised them for failing to admit any mistakes.
February 6: The chairman ruled that the inquiry should be suspended until at least February 24 to allow Attorney General Geoffrey Cox time after witnesses involved in the tower’s refurbishment asked for confirmation that any evidence given will not be used against them in any criminal proceedings that might take place.
March 3: The inquiry resumed, with evidence from Studio E. Studio E associate Bruce Sounes explained he had ‘no knowledge’ of rapid fire spread and had not read regulatory guidance about how to the design cavity barriers that were intended to stop fire spread and which failed at Grenfell. He had also not heard of Lakanal, or that aluminum cladding could burn.
An email was produced from Kate Cooney of Exona, four years before the project was signed off, suggesting that they had concerns about the safety of the (FF/MoE) Means of Escape shaft.
March 9: Neil Crawford, the lead architect for Studio E, revealed that Studio E had been on the point of terminating Exona in 2012 for failing to adequately scrutinise early proposals, and that a promised report on the safety of the revised cladding never arrived.
March 16: Following Prime Minister Boris Johnson’s statement on the coronavirus pandemic, the panel decided on the same day to suspend hearings.
July 6: Phase Two resumed. The inquiry heard claims that during the planning process Simon Lawrence, a key executive of Rydon, failed to respond to concerns that the cladding might be dangerous and that it could lead to a repeat of the Lakanal House tower fire in South London in 2009 which caused the death of six people.
Project emails show that Rydon, Exova, and the architects Studio E discussed the fire safety of the cladding before its installation, including warnings it might fail.
Tony Pearson, of Exova, told the architects: ‘If significant flames are ejected from the windows, this would lead to failure of the cladding system, with the external surface falling away and exposing the cavity.’
The inquiry was told that in November 2014, an official at KCTMO asked Simon Lawrence to clarify the ‘fire retardance of the new cladding’ but that Lawrence did not respond.
The inquiry also heard that Studio E manipulated its fees to avoid the contract being put out to open tender.
July 13: Building Consent was explored. RBKC were adamant that the new wall structure must include fire stopping barriers with a two-hour rating. However, Studio E architects found this unnecessary claiming the job was done by the cavity barriers.
July 20: Simon Lawrence, an executive of Rydon, the principal contractor, explained he knew that RBKC was attempting to save £800,000 on the job and to win the contract offered to save £293,368 by switching from the originally specified zinc cladding to the plastic-filled aluminium panels.
The bid was accepted and Mr Lawrence was not aware of the increased danger and hadn’t researched it.
July 21: David Gibson, head of capital investment from KCTMO [the landlord] recalled raising the panel safety issue with Mr Lawrence who said the plastic-filled panels were inert. MR Lawrence denies having said so.
July 22: The enquiry began to examine the contractors onsite behaviour. It heard that the contractors referred to the residents who criticised their workmanship as rebels and aggressive rebels. There were also claims that the residents had threatened the contractors, who were using inappropriate behaviour and language on site.
September 21: Evidence was given by the project manager Ben Bailey, the son of the owner of Harley, who were sub-contracting for Rydon.
He was not aware that changing materials for the project required consent from Rydon which had not been obtained. He also said the only assessment of its performance that he saw was of its thermal insulation, not its fire performance – and he was not aware that it was his job to check that.
Mr Bailey said that had no training in understanding building regulations or in keeping up-to-date with industry codes of practice for the design and installation of cladding and windows. He said it was never his role to be considering the fire performance of the materials.
September 29: John Hoban, senior building control surveyor at the Royal Borough of Kensington and Chelsea (RBKC), reported councillors had signed off substantial cuts to the building control department. It was ‘swamped’ with work as austerity-driven cuts slashed the staff numbers. The key surveyor was left managing handling 130 projects.
The council-owned tenant management organisation, the architect, main contractor and cladding contractor assumed the council’s building control department was ensuring that refurbishment did comply with the building regulations.
Mr Hoban had received no training or technical industry guidance and said reading professional magazines was considered as their continuing professional development. He had also not read the document about the fire performance of external thermal insulation for walls of multistorey buildings known as BR135.
It detailed a 1999 cladding fire in Garnock Court in Irvine, Scotland, and explained with pictures the rapid fire spread through cladding, and he was not aware of the guidance differentiating between non-combustible panels made from materials such as cement and combustible panels, including aluminium panels which may melt and create molten debris.
Mr Hoban identified two problems that afflicted his department and had led to the fire safety aspects of the cladding being missed. These were the austerity cuts between 2013 and 2017, that had lead to 10 experienced officers being replaced by one graduate trainee, and the stripping back of building regulations and enforcement bylaws together with a weaker building act.
October 6: The owners of the block, RBKC, had delegated all responsibility for maintenance to the TMO, the landlord, and deny any responsibility for the disaster.
October 16: The first contractor appointed reported that it couldn’t do the job for the amount tendered and it was to require a further £1.5million. The second contractor appointed was Rydon. Rydon’s refurbishment manager, Stephen Blake, and Peter Maddison, the TMO’s director of assets, had a longstanding professional relationship.
At an un-minuted meeting in March 2014, TMO and Rydon agreed how a further £800,000 could be shaved off a contract awarded to Rydon – this could be contrary to EU tendering law, being named value engineering. Rydon was given the contract.
October 26: Mr Maddison explained he was not aware that the panels were flammable. A further 50 per cent reduction had been extracted from the manufacturer, and Rydon had reduced its price by a further £800 000.
November 4: The inquiry started to examine the manufacturing, safety, testing and marketing of the cladding products. Barristers for the victims, in their opening statements repeated the charges that:
Arconic, which made the cladding sheets that were the main cause of the fire’s spread, obtained a certificate for its plastic-filled panels on ‘a false premise’ by supplying test reports for a more fire-retardant version of the product.
Celotex, which made the bulk of the combustible foam insulation used, displayed a ‘widespread culture … of ignoring compliance’, which included distorting a full-scale fire test of its materials. A former Celotex manager who had been involved agreed that the company’s actions were ‘deliberately misleading and dishonest’, saying he had been made to ‘lie for commercial gain’ with the approval of Celotex’s senior executives.
Kingspan, which made the rest of the insulation, carried out tests that involved either ‘concealing components in a manner designed to facilitate a pass and/or using materials that were not as described in the test reports’.
It was claimed by the barristers that the companies viewed the safety certificates as marketing tools and of little other importance.
Evidence was produced that the three manufacturers were aware of the deficiency of their product and worried about preventing these facts damaging their marketing and sales.
November 11: It was revealed in a conflict of interest statement that the Ministry of Housing awarded a £600,000 research grant to a consortium whose members include a fire testing specialist Eric Guillaume, whose research was funded by Kingspan, and José Torero, a fire engineer who has publicly opposed outright bans on combustible materials, subsequent to the tower fire.
November 16: Jonathan Roper, a former assistant product manager for Celotex, who worked on two fire tests of the foam panels and the subsequent sales plans, said the company behaved in a ‘completely unethical’ way. When the first test failed, they re-tested inserting additional fire retardant panels.
A senior technician, Ivor Meredith, responsible for safety tests on combustible insulation used on Grenfell Tower, had ‘a serious drug habit’ and fell asleep at work, the inquiry heard.
November 30: The inquiry learned that Kingspan director Philip Heath had said, in 2008, that consultants who raised concerns about the combustibility of its product could ‘go f**k themselves’, and that they were ‘getting me confused with someone who gives a dam [sic]’.
December 8: The inquiry saw evidence that in November 2016, Kingspan technical staff had acknowledged internally that Kingspan was selling its Kooltherm K15 foam insulation product as less flammable than it really was.
A version of K15 had correctly tested safe in 2005, but Kingspan had changed the formula for a more flammable foam; marketing it on the old safety certificate. Kooltherm K15 was present in the cladding that caught fire.
December 9: The inquiry learned that after the Grenfell fire, Kingspan had invested in a smear campaign against rival companies’ products. The campaign involved secretly using non-standard test rigs to artificially create the appearance that non-flammable rival products might in fact be flammable, and hiring lobbyists to push the results before the Ministry of Housing and other MPs.
December 14: Grenfell United delivered a letter appealing to the French Ambassador, Catherine Colonna, to exert moral pressure on three key witnesses from Arconic who refused to testify.
February 9, 2021: Debbie French, a former sales executive at Arconic who had sold the panels to Grenfell, explained that Arconic also sold a fire retardant version of the panel – but the default version of the panel, which was cheaper, was highly flammable.
February 17: Claude Schmidt, Arconic’s president, spoke of the two versions of the Reynobond PE panel, the rivetted version and the cassette version, and that the regulatory document issued by the British Board of Agrement (BBA) in 2008 did not distinguish between the two types of Reynobond panel.
Under cross-examination, Mr Schmidt confirmed that Arconics should have informed the BBA about the test.