A Catalogue of Systemic Failure

The fifth anniversary of the Grenfell Tower fire is less than a week away.

The shocking revelations from the Grenfell Tower Inquiry have been heard by too few.

With Pete App's permission I'm reproducing his epic thread about Phase 2 of the Inquiry thus far, with links to all the articles which give more detail. Everyone involved in construction, housing and policy and regulation should read this thread. It is on Twitter here.

1. In an email exchange in March 2015, designers of the tower's cladding system wrote: “There is no point in ‘fire stopping’. As we all know; the ACM will be gone rather quickly in a fire!"

2. The architects were appointed despite an almost total lack of experience designing high rise cladding systems. An open procurement process was deliberately avoided by splitting their fee.

3. The architect responsible for the early design and specification of the cladding system was not aware of the basic rules surrounding compliance and did not take steps to familiarise himself with them.

4. A consultant from fire engineering experts Exova described the plans for the refurbishment as "not great" and "making an existing crap condition worse".

5. The fire engineering consultant appointed to review the plans was not a qualified fire engineer. But he had previously worked with the building control inspectors in Kensington who would sign the project off. Colleagues called him "the man for contacts down there"

6. Despite being emailed details of the cladding system, this consultant, Terry Ashton, made no assessment of the plans and instead produced a report saying the refurbishment would have "no adverse effect in relation to external fire spread".

7. This conclusion was to be confirmed in a final version of the report, but it was never written, with contractor Rydon ditching the fire engineers to save money - despite telling project meetings they planned to retain them.

8. A Rydon manager described residents who complained about the refurbishment as 'rebel residents' in an internal email and doubled down on his criticism of them when he gave evidence.

9. Rydon, which had submitted the lowest bid for the refurbishment contract, was tipped off they were in first place and held an 'offline' meeting with KCTMO to cut ￡800,000 of cost, which included switching the cladding for the highly combustible ACM.

10. Rydon hid the true cost savings which could be made from this switch and intended to 'pocket the difference'. One employee wrote "we will be quids in!"

11. Ray Bailey, the boss of cladding sub-contractor Harley, appointed his 25-year-old as project manager despite the fact that he had one job's prior experience.

12. Mr Bailey said he "took it on trust" from the manufacturers of the cladding products that the materials complied and described his "confusion" about basic fire standards for these products.

13. The commercial manager at this firm encouraged the architects to switch to cheaper ACM cladding. An email from the firm which cut and sold these panels later promised him a "very nice meal very soon somewhere very nice” when the deal was secured.

14. The combustible insulation was selected after architects and engineers selected an "aspirational" standard for thermal efficiency, beyond what was required by law and described as "over the top" in internal documents

15. A warning that there was a "weak point for fire" at the top of new windows due to a missing cavity barrier resulted in no action to remedy it. Fire would later break through the windows to ignite the cladding.

16. The tower's building control surveyor accepted his work "fell below the standards of a competent surveyor", including not properly checking whether the combustible cladding products complied with the rules.

17. The Royal Borough of Kensington and Chelsea cut its building control team from 12 to four in the years before the fire, with the inspector who reviewed Grenfell working on 130 projects simultaneously.

18. KCTMO was warned the refurbishment would "fail" unless the budget was raised, but "strongarmed" its consultant into changing its report on this point and with "value for money" made the key driver of the project.

19. A KCTMO project manager binned notebooks covering her time working on the refurbishment before they could be examined by police.

20. The same project manager, Claire Williams, emailed Rydon in November 2014, saying she had been thinking of the Lakanal House fire and wanted to check if the cladding was fire safe. There is no record of a reply.

21. Lawyers for bereaved and survivors described cladding and insulation manufacturers as "crooks and killers" and accuse them of a "sinister" attempt to undermine building regulations.

22. Insulation manufacturer Kingspan withdrew a test which had formed the basis of its claim that the product was suitable for use on high rises for years, admitting it was carried out on a legacy product removed from the market in 2006.

23. It is revealed cladding manufacturer Arconic had testing from 2004 which showed the devastating fire performance of its ACM, but kept selling it. Internal emails discussing this say: ‘It’s hard to make a note about this because we are not clean’.

24. A former technical officer explained how Celotex, which made most of the tower's insulation, added secret fire resisting boards to a key test to help sell its product on high rises. He said this was a direct reaction to pressure to boost profit.

25. Celotex used this test to help it obtain an LABC certificate which erroneously said its combustible product could be used on high rises “with a variety of cladding systems”. A former manager admits this was "intentional" and "dishonest".

26. When Kingspan tested a system including the new version of its insulation in 2007, the test resulted in a "raging inferno" with the insulation "burning on its own steam". This test was kept secret - even from other parts of its own business.

27. When a consultant queried the suitability of Kingspan's insulation for high rises, a former manager said they could “go fuck themselves” or Kingspan would “sue the arse [off] them”.

28. Kingspan got a certificate wrongly suggesting its insulation was 'limited combustibility'. “We threw every bit of fire test data we could at him, we probably blocked his server," writes one manager. "We didn’t even have to get any real ale down him!”

29. When the country's largest building control inspector, the NHBC, threatens to write to builders warning them Kingspan's insulation is unsuitable for high rises, the firm threatens to sue them for libel.

30. Discussing the company's claim that its insulation has a 'Class 0' fire performance, one employee texts another to call its testing "a bit of a cheat". "Alls we do is lie in here," his colleague replies.

31. Arconic told its sales people to stop advertising its cladding as having a B fire grade in April 2014, as it actually achieved E. But salesperson Debbie French used a certificate with the B grade to help win the Grenfell job two months later.

32. Arconic’s president accepted the firm told a ‘misleading half truth’ in not disclosing serious test failures to certifier the BBA to obtain a crucial certificate for its UK sales.

33. A senior member of Arconic’s technical team said that while the product was dangerous and was progressively being banned around Europe “we can still work with national regulations who are not as restrictive”. One of these was the UK.

34. An Arconic marketing manager speculated about the potential for a cladding fire in a high rise with its cladding killing ‘60/70 people’ in an internal document in 2007. The final death toll at Grenfell was 72.

35. A technician at testing house the Building Research Establishment claimed not to have known about Celotex’s secret fire resisting boards, despite helmet cam footage of him saying “see how that flame seems to have ceased now that the board is there”.

36. The BRE agreed to write a test report for Kingspan on a failed test but did not make it immediately clear that the test had failed. It was used to support ‘desktop studies’ supporting the use of the insulation on 29 buildings.

37. Certifier the British Board of Agrement published a materially wrong certificate incorrectly confirming the fire rating of Arconic’s cladding after the manufacturer simply ignored their requests for an update on testing data.

38. The BBA also committed a “very basic failure of due diligence” in using fire test data from different Kingspan products to produce a certificate about its K15 insulation, which was used on Grenfell.

39. Kingspan hired expensive public relations firms to help launch a lobbying campaign after the fire to prevent a ban on combustible building materials.

40. This included presenting information on a test on non-combustible products to a select committee, which had been designed to fail. A manager denied it was seeking to ensure “science was secretly perverted for financial gain”.

41. Pointing to figures showing 40% of the residents with severe mobility issues died, lawyers for bereaved and survivors call the fire "a landmark act of discrimination against the disabled and vulnerable".

42. When residents of the tower set up a group to complain about the refurbishment, KCTMO refused to meet with them - branding the group a 'showcase' for resident Eddie Daffarn.

43. Another resident warned KCTMO about concerns with the tower's provisions for escape in March 2017. “If we cannot get out people will die," he wrote. Calls for an independent investigation were rejected.

44. After being warned that the smoke control system in Grenfell Tower was "beyond repair", KCTMO took six years to replace it. "Let us hope our luck holds and there isn't a fire," wrote the head of health and safety.

45. In 2014, KCTMO had a backlog of 1,400 actions arising from fire risk assessments incomplete. Minutes record the organisation decided not to disclose the backlog to the fire service as “this would result in more scrutiny from the LFB and also possible enforcement action”.

46. When residents requested details about the smoke ventilation system under FOI, KCTMO declined to provide it writing internally that it could result in Eddie Daffarn writing critical articles on his blog.

47. KCTMO employees told the inquiry the reason they made no effort to prepared evacuation plans for disabled residents was government-endorsed guidance which said doing so was "usually unrealistic".

48. Council leader Nicholas Paget Brown described dealing with complaints about the refurbishment as a "dry run" for "some actual estate renewal". A consultancy had suggested demolition of the estate where Grenfell was located.

49. After a fire in a nearby tower revealed a major issue with missing self-closers on flat entrance doors, LFB called for a major replacement programme. But RBKC rejected this due to budget.

50. A deficiency notice was specifically served on Grenfell Tower by the LFB in November 2016, raising the issue of self-closers. Action was not taken. Missing self-closers is a major reason why smoke spread so fast internally.

51. The tower's fire risk assessor included a series of post-nominals on his CV which related to non-existent qualifications. He also copy and pasted between assessments, referring to pigeon netting and balconies at Grenfell (it had neither).

52. When LFB asked if there were any disabled residents in KCTMO's stock, he advised the organisation to "say you have no one" because "If you identify anybody now questions like why were they not including in the buildings risk assessment spring to mind".

53. When Grenfell Tower's smoke control system was finally replaced in 2016, a new bespoke system was fitted which did not comply with guidance and used the lowest quality options for key components.

55. In 2011, when the aforementioned government guidance on the evacuation of disabled people was published, an expert warned ministers it was "discriminatory" and could result in "an unnecessary tragedy".

56. And now we move to the inquiry's investigations of the LFB before the fire.

After a deadly fire in south London, the LFB was told to train incident commanders to deal with a major high rise fire. The new training package was never fully rolled out.

57. A senior LFB officer feared issuing a clear warning about the risks of dangerous cladding before the Grenfell Tower fire would be "let the cat out of the bag" about the extent of dangerous systems.

58. The LFB's head of fire engineering prepared a presentation for a conference which discussed the "significant threat" of fire spreading across the outside of tall buildings. But its front line staff were never warned of this risk.

59. Asked to redraft national guidance for high rise fire fighting after Lakanal House, the LFB failed to include sections on reversing stay put and evacuation despite a specific promise made to the coroner.

60. LFB promised to train its call handlers to give better advice to residents trapped by fire following Lakanal, but substantially limited it due to budget concerns and major IT problems.

Moving on to testing, certification and the building regs...

61. The UK's largest private building control inspector continued to accept combustible insulation on high rises, despite its own fire engineer calling it "an accident waiting to happen".

62. A cladding supplier warned government officials of his "grave concerns" about the use of Grenfell-style cladding in the UK after telling a conference "an exact repeat" of huge cladding fires in the UK could happen in London.

63. The government sought independent experts to give scripted rebuttals to media reports critical of building regulations days after the Grenfell fire.

64. A government-commissioned 'catastrophic' test on the exact type of cladding used on Grenfell meant the UK government should have had 'no doubt at all' that it should have been banned.

65. The government was warned the UK faced becoming a 'dumping ground' for Europe's combustible building products if it didn't tighten standards in the early 2000s - but failed to do so amid industry lobbying.

66. The government contractually prohibited a fire investigation group from recommending changes to building regulations as a result of its investigations.

67. The government "shut down" a nascent investigation into the fire at Lakanal House in 2009, before crucial questions about the reason for its rapid fire spread had been answered.

68. Deregulation rules such as "one in two out" meant officials felt unable to implement the recommendations of the Lakanal House coroner and left them "trapped between a rock and a hard place".

69. The official responsible for fire safety guidance described the type of cladding later used on Grenfell by writing: ‘When exposed to a fire, the aluminium melts away and exposes the polyethylene. Whoosh!’

70. Despite this, he did not pass on a "red alert" warning that the cladding was in wide use in the UK, and said he "forgot" to publish a clarification requested by an expert group making clear it was banned.

71. After the Lakanal House coroner recommended a review of fire safety guidance, with particular regard to external fire spread, an internal govt doc said this “would require significant resources and have a disruptive effect on the construction industry”.

72. When a group of MPs chased ministers for the review to be completed, they replied to say they had "neither seen nor heard anything that would suggest these specific changes are urgent and were not willing to disturb the work of this department to bring them forward.”

73. When he was called to give evidence, the secretary of state in this period, Eric Pickles, insisted deregulation had nothing to do with these failures and got the the number of victims of the fire confused with Hillsborough.

74. After the fire, the government published a letter to industry which misleadingly suggested combustible cladding was banned by its guidance. The official involved denied it was a “planned, deliberate and underhanded” attempt to protect its position.

75. In the aftermath of Grenfell, residents were left without support or information. Some of those displaced slept rough. Some searching for loved ones were threatened with arrest.

76. The council failed to call on available external support to help deal with the aftermath, telling colleagues "that looks like we can't cope". As its response collapsed it accused "embittered residents" "painting the situation in a poor light" to "incite a mob".

Pete adds to the end of the thread, the following:

And there is a highlights reel tour of a two-and-a-bit year inquiry into the background to Grenfell. It is still continuing, with final expert evidence and factual examination of the circumstances of each death due to run to July. I will leave it down to you to decide what this evidence tells us about who is to blame and the kind of world we all live in. For me, the facts tend to speak for themselves.

What is clear is that the sum result of the many, many failures described above and more was 72 deaths and a community decimated and traumatised by the worst disaster that has happened in this country for decades.

Next week, their families and friends will be coming together to remember them and call for justice and change. If they are going to get it, it's important for all of us to show them support and solidarity and to not forget about what happened and why.