Multiple failings and systemic negligence have been identified as contributing factors to the deadly fire that killed 72 residents of a 24-storey apartment building in the United Kingdom in 2017. The newly released report and recommendations from a UK government sponsored inquiry into the Grenfell Tower fire casts a wide net of blame, beginning with the manufacturers and marketers of the exterior cladding systems that served as a welcoming and rapid path for travelling flames.

Beyond those actions — which the three-member inquiry panel calls “dishonesty” — the report is highly critical of various oversight and certification bodies that are central to the safety and performance of the built environment. Although building codes in other countries, including Canada, have not allowed designers, developers and building owners to make the choices that directly led to the Grenfell Tower catastrophe, there are arguably lessons for onlookers everywhere about slipshod diligence, inappropriately trained and/or overworked safety administrators and the possible risks of commercial pressures in regulatory and certification processes.

“It is not possible to identify any single cause of the tragedy; many different acts and omissions combined to bring about the Grenfell Tower fire, although some were more significant than others,” the introduction to the report states. “We have identified many errors, due in the most part to incompetence, carelessness and a failure to take responsibility for important aspects of the work that affected fire safety.”

Notably, the report finds fault with:

• the UK’s Building Research Establishment (BRE), a 103-year-old organization that develops standards, conducts testing and research, oversees industry and professional certifications such as BREEAM, and is widely recognized for its expertise, including related to fire, safety and security;
• the British Board of Agrément (BBA), an independent certification body for the construction and civil engineering industries, including certification of construction products;
• the National House Building Council (NHBC), an independent warranty and insurance provider for new home construction, including standards, training and quality assurance for builders;
• the United Kingdom Accreditation Service (UKAS), the national body tasked with assessing and accrediting organizations that provide certification, testing, inspection, calibration, validation and verification services;
• the Local Authority Building Control (LABC), a joint agency of the UK’s municipal governments, intended to provide centralized technical support, training, marketing and business development services for its members’ building control departments;
• the Tenant Management Organisation (TMO), an organization established under the UK’s housing regulations to provide services to housing communities on behalf of their public landlords; and
• local building officials with the Royal Borough of Kensington & Chelsea.

Commercial pressure impinges on testing and certification

The inquiry panel concludes BRE was complicit in enabling the manufacturer of the combustible polyisocyanurate foam insulation used on the Grenfell Tower to pass fire safety testing. When the product was tested in BRE labs in May 2014, “two sets of fire-resistant magnesium oxide boards” were used to augment its resistance, but that fact was omitted was BRE’s subsequent fire safety report.

The inquiry panel also underscores that BRE had been aware of fire safety issues with the cladding in question as early as 1991, but had failed to effectively communicate such concerns to government authorities or to properly identify its contributory factors in at least three noteworthy fires investigated prior to the Grenfell Tower catastrophe. BRE’s testing of the fire safety of external walls is negatively cited for “unprofessional conduct, inadequate practices, a lack of effective oversight, poor reporting and a lack of scientific rigour”.

This is partly attributed to organizational failure to properly train staff or instill a culture of responsibility. Egregiously, senior staff at BRE were found to have coached manufacturers on how to get better safety testing results.

“In some cases we saw evidence of a desire to accommodate existing customers and to retain its status within the industry at the expense of maintaining the rigour of its processes and considerations of public safety,” the inquiry report states.

Similarly, the BBA is chastised for “an ingrained willingness to accommodate customers” exhibited in its deference to the manufacturers of the combustible cladding. The inquiry panel maintains the BBA lacked both the required expertise to assess the manufacturers’ disingenuous conduct and the robust processes to catch it. It did not assess any aspect of the product’s manufacture, testing or fire performance, and allowed the manufacturer to supply wording for the certificate.

“The underlying problem was that the BBA failed to manage the conflict between the need to act as a commercial organisation in order to attract and retain customers and the need to exercise a high degree of rigour and independence in its investigations in order to satisfy those who might consider relying on its certificates,” the report states.

As the cascading consequences of Grenfell Tower catastrophe demonstrate, subsequent product specifiers/purchasers and oversight agencies rarely reassess, question or dispute certifications. Overreliance on the honour system opened the way for other safety players to overlook misconduct.

The Local Authority Building Control is criticized for failing to ensure competent assessment of products or scrutiny of manufacturers’ claims. United Kingdom Accreditation Services is called out for an approach that relies too much on “the candour and co-operation of the organisations being assessed” and lacks repercussions for accredited organizations’ missteps or encouragements and supports for their improvement.

Like BRE and BBA, the National House Building Council is accused of succumbing to commercial pressure. The inquiry panel suggests the NHBC was well placed to sound the alarm about combustible cladding, particularly through its large contingent of accredited inspectors providing services to the building industry, but it failed to adequately do so.

“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,” the inquiry report asserts.

On-site decision-makers called careless and incompetent

Drilling down to on-site at the Grenfell Tower, numerous failings are highlighted in the management, delivery and oversight of the recladding project that precipitated the disaster, and in fire safety monitoring and coordination within the building. The tenant management organisation, the local government authority (which was both the landlord and the building department of record) and the contractor are all held culpable.

“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. 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,” the inquiry report states. “None of those involved in the design of the external wall or the choice of materials acted in accordance with the standards of a reasonably competent person in their position.”

Of these, the building department is flagged for “considerable responsibility” in failing to ensure the project complied with building regulations. The surveyor assigned to the project is described as overworked, inadequately trained and lacking understanding of the risks of the materials involved.

Nor do senior government officials escape scrutiny. The UK government is lambasted for: its complacency related to fire safety; failing to act on well documented evidence of the cladding system’s combustibility; failing to amend the Fire Safety Order (equivalent to the Fire Code) to clarify that it applied to exterior walls of multifamily dwellings; and for resisting calls to regulate fire risk assessors.

The newly released report arises from the second phase of the public inquiry, which former UK Prime Minister Theresa May announced immediately after the fatal fire occurred. Findings are drawn from documentary resources and oral evidence presented in 312 days of proceedings.