| The government (department of Communities) |
- Since the fire at Knowsley Heights in 1991 the government had opportunity to identify risks posed by use of combustible cladding
|
| Building Research Establishment (BRE) |
- Independent Building Materials Researcher and tester – undertook a large-scale test on Aluminium Composite Panels (ACP) reaction to fire in 2001, but failed to draw the governments attention to the way the material behaved and the dangers it presented
- BRE senior staff advised Cladding manufacturers as customers, compromising its integrity and independence.
- It also accepted the inclusion of magnesium oxide boards in the cladding system when testing large scale fire impacts. These were added by the cladding manufacturers to mask the true fire characteristics of the boards thereby allowing them to pass the tests.
|
| Cladding Manufacturers (namely Arconic Architectural Products, Celotex and Kingspan) |
- “Systemic dishonesty”
- “Deliberately concealed from the market the true extent of the danger… particularly on high rise buildings”
- “was determined to exploit what it saw as weak regulatory regimes in certain countries…”
|
| The British Board of Agrément (BBA) |
- Commercial organisation that certifies the compliance of products with the requirements of legislation.
- BBA certified one of the cladding products and its certificates were largely accepted by industry without question.
- The dishonest strategies of the manufacturers succeeded due to the incompetence of the BBA and its willingness to accommodate customers.
- The BBA did not assess any aspect of the [Cladding] product’s manufacture, testing or fire performance.
|
| Local Authority Building Control (LBAC) |
- Formed by local authorities to provide building control training and technical matters.
- It issued certificates verifying the compliance or construction products and systems.
- There was a complete failure by LBAC over a number of years to take basic steps to ensure that the certificates it issued regarding cladding were technically accurate.
- “It was willing to accommodate the customer (cladding manufacturers) at the expense of those who relied on the certificates.”
|
| The National House Building Council (NHBC) |
- NHBC employed a large number of approved inspectors through whom it provided building control services (inspectors/certifiers).
- It was unwilling to upset its construction customers and the wider construction industry by revealing the scale of the use of combustible cladding.
- A conflict between the regulatory function of building control and the pressures of commercial interests…
|
| United Kingdom Accreditation Service |
- Did not always follow its own policies and its assessment processes lacked rigour.
- The process relied too much on the candour and co-operation of organisations being assessed and too much was left to trust.
|
| The Tenant Management Organisation (TMO) |
- The body who managed the building and its residents.
- The TMO lost sight of the fact that the residents were people who depended on it for a safe and decent home.
- Between 2009 and 2017 there was a persistent indifference to fire safety, particularly the safety of vulnerable people.
- There was no system for ensuring that defects identified in the fire risk assessments were remedied effectively and in good time.
- The demands of managing fire safety were viewed by the TMO as an inconvenience rather than an essential aspect of its duty to manage the property carefully.
- Failed to ensure that the fire safety strategy be produced by the fire engineer during the refurbishment project.
|
| Royal Borough of Kensington and Chelsea (RBKC) |
- RBKC and TMO were jointly responsible for the management of fire safety at Grenfell Tower.
- RBKC oversaw TMO’s activities and oversight of TMO’s performance was weak and fire safety was not subject to any key performance indicator.
- There was an absence of any independent or rigorous scrutiny of the TMO’s performance of its health and safety obligations.
- Evidence found of RBKC taking little to no account of highly critical independent fire safety report undertaken by TMO in 2009.
|
| RBKC Building Control |
- RBKC building control did not properly scrutinise the design or choice of materials for the refurbishment and failed to satisfy itself that on completion of the work the building would comply with the requirements of the building regulations.
- The surveyor used was overworked, inadequately trained and had limited understanding of the risks associated with ACM panels.
- He also did not ask whether the fire engineer had provided a completed fire safety strategy.
|
| TMO’s CEO |
- There was an entrenched reluctance for the CEO to inform the board and RBKC’s scrutiny committees of matters that affected fire safety
|
| TMO’s Fire Assessor |
- Was ill-qualified to carry out assessments on buildings of the size and complexity of Grenfell Towers.
- Often failed to check whether the TMO had taken action in response to risks he had identified in previous assessments.
|
| The Architect responsible for the Refurbishment Design (Studio E) |
- Took a casual approach to contractual relations.
- They did not understand the nature and scope of the obligations they had undertaken.
- They failed to identify their own responsibilities for important aspects of design and in each case assumed someone else was responsible for matters affecting fire safety.
- The risks of using combustible materials in the external walls were well known, they should have been aware of them.
- Ultimately responsible for the choice of external wall covering and “bears a very significant degree of responsibility for the disaster”.
|
| The Building Consultant acting as the TMO’s agent and quantity surveyor for the refurbishment (Artelia) and The Principal Contractor who build the refurbishment (Rydon) |
- Gave inadequate thought to fire safety, and its systems for managing design work did not ensure that its sub-contractors and consultants properly understood their different responsibilities.
- Its team was inexperienced and did not have sufficient knowledge of the Building Regulations.
- It was complacent about the need for Fire Engineering advice and made the call to not proceed with the fire engineer without consulting other members of the design team or the TMO.
|
| Cladding Subcontractor (Harley) |
- Did not include cavity barriers in its external wall design (though this should have been picked up by the Architect).
- It did not concern itself with fire safety at any stage of the refurbishment.
- Believed that ultimately Building Control (Building Surveyors) would ensure that the design was safe.
- It was induced to buy the cladding panels by manufacturers.
- Harley accepted the panels for use without enquiring in any detail whether they could be safely used.
|
| Fire Engineer (Exova) |
- Was instructed by Studio E to prepare a fire safety strategy for the building post refurbishment.
- A draft was prepared but never completed.
- It did not include an analysis of the external wall or its compliance with functional requirements of the building regulations.
- Failed to raise its incomplete work with the design team.
- None of the design team visited the site.
|
| The London Fire Brigade |
- Having been exposed to a significant Tower Fire in 2009, they had failed to learn from this experience, build processes to deal with such events and train these processes to their management and teams.
- “A chronic lack of effective management and leadership.”
|
