Chapter 11: Combustible cladding: warnings to government

Chapter 11: Combustible cladding: warnings to government

¶11.1 Between 2012 and 2017 the government received warnings from many sources about the use of combustible materials in the construction of the external walls of high-rise buildings. They included specific warnings about the risks posed by polymeric insulation products and aluminium composite cladding products with unmodified polyethylene cores. However, the government failed to provide guidance on how to avoid the dangers posed by the use of combustible materials or to take any other action in response to the warnings it had received. As a result an increasing number of high-rise buildings were constructed using dangerous materials.

2012–2013: international cladding fires

¶11.2 Throughout the period from 2012 to 2017 Brian Martin was the department's principal construction professional^13781378 Martin {CLG00019469/1} page 1, paragraph 2. and primary custodian of Approved Document B.^13791379 Martin {Day252/206:3-7}. On 17 and 18 May 2012, he received emails from Dr David Crowder of the BRE attaching links to news reports, including video footage, of a fatal cladding fire that had occurred on 14 May 2012 at Mermoz Tower, an 18-storey block of flats in Roubaix, France.^13801380 {CLG00019178}; {CLG00019179}; Martin {CLG00019469/36-37} pages 36-37, paragraph 109. In his response to that email, sent to Sir Ken Knight, Louise Upton and Anthony Burd, Mr Martin described the video as "pretty alarming" and expressed the view that a construction of that kind would probably not be in accordance with the Building Regulations.^13811381 {CLG00019179}. Mr Martin said "probably", because he did not have enough information at the time to determine whether the building's façade would have complied with functional requirement B4(1) of the Building Regulations.^13821382 Martin {CLG00019469/36-37} pages 36-37, paragraph 109. He said that he had had a limited amount of time to look into the fire and that he did not think he had discovered until after the fire at Grenfell Tower that Mermoz Tower had been clad in aluminium composite panels with polyethylene cores.^13831383 Martin {Day252/107:16-25}. Anthony Burd did not consider carrying out a review to find out whether any buildings in this country had been constructed using similar materials.^13841384 Burd {Day240/151:1-6}. He said that he had not had the time or the information necessary to do so.^13851385 Burd {Day240/153:2-7}; {Day240/152:6-17}.

¶11.3 On 5 December 2012, following another cladding fire on 18 November 2012 at Tamweel Tower, a residential high-rise building in Dubai, Mr Martin and Mr Burd received an email from Sam Greenwood at BRE,^13861386 Sam Greenwood was a consultant at BRE, reporting to Martin Shipp, and had investigated the fire at the Edge in January 2005 alongside Dr Colwell: Shipp {BRE00047594/82} page 82, paragraph 461; Colwell {BRE00047571/44} page 44, paragraph 270. in which he compared the fire at Tamweel Tower to the fire at The Edge in Salford in January 2005.^13871387 {CLG00019192}. For the details of that fire see Chapter 8. Mr Martin may already have been aware at that time of the Tamweel Tower fire and of the fact that it had involved aluminium composite cladding with a polyethylene core.^13881388 Martin {Day252/111:12-16}. When responding to Mr Greenwood's email he remarked on what he described as the "awesome" power of the fire in the videos he had seen of the event.^13891389 {CLG00019192}; Martin {CLG00019469/37} paragraph 110; Martin {Day252/110:1}-{Day252/111:3}. However, it was his view that such a fire could not occur in this country^13901390 Martin {CLG00019469/37} page 37, paragraph 110; Martin {Day252/110:20}-{Day252/112:1}. because he understood that people were following the guidance in paragraphs 12.5 and 12.7 of the 2006 version of Approved Document B.^13911391 Martin {Day252/111:4-10}. The purpose of paragraphs 12.5 and 12.7 had been to encourage people to think beyond insulation^13921392 Martin {Day252/112:5-7}. and he had thought that the guidance they contained was both adequate and sufficiently well understood to prevent a fire of that kind occurring here.^13931393 Martin {Day252/112:17}-{Day252/113:13}.

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November 2013 to January 2014: questions from BRE

¶11.4 Brian Martin did not become aware that the application of section 12 of Approved Document B was causing difficulties in practice until late 2013.^13941394 Martin {Day252/158:12-14}. The construction of external walls had not been a prominent feature of his work before that.^13951395 Martin {Day252/159:9-11}. The first time he was asked about the meaning of paragraph 12.7 was on 25 November 2013,^13961396 Martin {Day252/184:3-6}; Martin {Day253/23:6-10}. when he received an email from Tony Baker of BRE,^13971397 {CLG10005895}. who told him that BRE was receiving an increasing number of inquiries about the interpretation of Diagram 40 and paragraphs 12.6 and 12.7 of Approved Document B. Mr Baker hoped to reach a general understanding with the department so that BRE could give consistent advice to those who contacted it. Mr Baker referred to a debate that had arisen within the construction industry about how paragraph 12.7 and Diagram 40 were intended to apply to boards used as the outer layer of an external wall. He suggested that a definition of the words "finish" (paragraph 12.6) and "filler" (paragraph 12.7) would help to clarify the matter.^13981398 {CLG10005895/2-3}.

¶11.5 In response Mr Martin said that he thought it was reasonable^13991399 Martin {Day252/188:21-23}. to interpret those paragraphs as meaning that a homogenous^14001400 Defined in EN 13501 as "a product consisting of a single material, having uniform density and composition throughout the product": {BSI00001738/10} paragraph 3.1.3. board that was Euroclass B would be fine,^14011401 {CLG10005895/2}. in that all of it could be classed as a "surface" and therefore need not be of limited combustibility, but that a composite board was subject to the guidance on limited combustibility in paragraph 12.7.^14021402 Martin {Day252/188:15-20}; {CLG10005895/2}.

¶11.6 Mr Martin told us that the question Mr Baker had raised was not one that he and Mr Burd had considered in 2006 when drafting the amendment to paragraph 12.7 of Approved Document B,^14031403 Martin {Day252/190:1-15}. but that in his view, Mr Baker's assessment of the relevant provisions^14041404 {CLG10005895/1}. was accurate,^14051405 Martin {CLG00019469/39-40} pages 39-40, paragraph 116; Martin {Day253/5:4-19}. in that paragraph 12.6 directed readers to consider the surface of a wall while paragraph 12.7 directed readers to consider materials below the surface.^14061406 Martin {Day252/198:7-17}; Martin {Day253/6:14-15}; {Day253/7:10-15}. The obvious difficulty with that explanation, however, is that paragraph 12.7 did no such thing.^14071407 Martin {Day253/7:16-25}. Instead, it directed readers in clear terms, both by the heading and the text, to consider insulation materials. Perhaps unsurprisingly, Mr Baker was not satisfied with Mr Martin's responses^14081408 Baker {BRE00043700/8-9} pages 8-9, paragraph 45. and asked for a meeting in order to resolve the matter.^14091409 {CLG10005895/1}; Martin {Day253/15:14-19}.

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¶11.7 A meeting subsequently took place between Mr Baker, Dr Colwell and Mr Martin on 30 January 2014.^14101410 {CLG10005953}; Baker {BRE00043700/14} page 14, paragraphs 72-75; Colwell {Day233/160:9-13}. Neither Mr Baker^14111411 Baker {BRE00043700/15} page 15, paragraphs 78-82. nor Mr Martin could remember much, if anything, about it^14121412 Martin {CLG00019469/39-40} pages 39-40, paragraph 116; Martin {Day253/24:21-23}. but Dr Colwell recalled that Mr Martin had accepted that paragraph 12.7 could have been written more clearly.^14131413 Colwell {Day233/164:25}-{Day233/165:4}.

¶11.8 Despite having been made aware that there was uncertainty in the construction industry about the meaning and effect of paragraphs 12.6 and 12.7 of Approved Document B, Mr Martin took no steps to provide clarification. Mr Martin does not appear to have been troubled by the fact that the provisions were not well understood^14141414 Martin {Day252/191:6-12}. and did not ask BRE who had been raising questions.^14151415 Martin {Day252/182:24}-{Day252/183:2}. Nor did he ask how many there were or how often they were received. In short, he made no attempt to understand how those paragraphs of the guidance were being understood by those who had to use it.

¶11.9 Mr Martin saw no need to tell his managers that there was a problem that required attention in one form or another,^14161416 Martin {Day253/29:8-14}; {Day253/30:20-23}. apparently because he did not consider it to be urgent^14171417 Martin {Day253/20:20}-{Day253/21:3}. or particularly significant. He did not, therefore, raise it with Richard Harral, who by January 2014 had replaced Anthony Burd as Head of Technical Policy,^14181418 Harral {CLG00019487/1} page 1, paragraph 3. or with his Deputy Director, Mr Ledsome.^14191419 Martin {Day252/185:22-24}; Martin {Day253/29:8-14}; Harral {Day244/72:15-19}; Ledsome {Day242/190:19-23}. Both told us that they would have expected him to draw to their attention matters of the kind that were being raised by BRE.^14201420 Harral {Day244/74:23}; {Day244/74:14-15}; Ledsome {Day242/194:8-12}. Instead, Mr Martin proceeded on the basis that the questions that BRE was receiving showed that the guidance was making people think broadly.^14211421 Martin {Day252/193:18}-{Day252/194:10}. In any event, he did not consider himself to be the ultimate arbiter of the meaning of any particular part of the guidance,^14221422 Martin {Day252/200:7}-{Day252/201:3}. the function of which, in his view, was to help people to make their own judgments about what was required to comply with the functional requirements of the Building Regulations.^14231423 Martin {Day252/194:11-18}. He also thought that industry was producing its own guidance on how to comply with functional requirement B4.^14241424 Martin {CLG00019469/54} page 54, paragraph 155; Martin {Day252/166:10-22}.

¶11.10 Although Dr Colwell thought that Mr Martin had taken BRE's concerns seriously,^14251425 Colwell {Day233/162:2-6}. neither she nor Mr Baker thought that the question they had raised had received a definitive answer.^14261426 Baker {BRE00043700/15} page 15, paragraph 83; Colwell {Day233/165:10-14}. He told them that the matter would be picked up in the next review of Approved Document B,^14271427 Colwell {Day233/160:19-25}; {Day233/164:17-19}; Baker {BRE00043700/15} page 15, paragraph 83. which he envisaged would start a year later, when the department's work on the Housing Standards Review had been completed.^14281428 Martin {Day253/25:25}-{Day253/26:4}. In the event, however, that did not happen.

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An FAQ?

¶11.11 From time to time the department published on its website answers to "Frequently Asked Questions", which themselves became known as "FAQs".^14291429 Harral {Day243/60:24}-{Day243/61:7}; {Day244/46:25}-{Day244/47:4}; Ledsome {Day241/181:15-21}. For an example of an FAQ in relation to Approved Document B {CLG10000003}. It seems likely that the possibility of clarifying the meaning and scope of paragraph 12.7 by publishing an FAQ had been raised at the meeting.^14301430 Baker {BRE00043700/15} page 15, paragraphs 82-83. Under certain circumstances that could be done without the need for any formal process of review.^14311431 Harral {Day244/41:14-20}; Ledsome {Day242/158:2-16}.

More international cladding fires

¶11.12 Following the fires in the United Arab Emirates in 2012 and 2013, Dr Colwell had travelled to Dubai several times to work with the authorities there on revising their fire safety codes^14321432 Colwell {Day233/208:18}-{Day233/210:10}. and was aware that those fires had involved aluminium composite cladding panels with polyethylene cores.^14331433 Colwell {Day233/54:23}-{Day233/55:3}; {Day233/208:14-16}. She said that she had discussed some of them with Mr Martin during the meeting in January 2014. He did not recall that but we think it likely the subject was raised on that occasion.^14341434 Martin {Day252/118:7-11}.

¶11.13 Mr Martin could remember being aware in 2014 of some, but not all, of the fires involving aluminium composite material with a polyethylene core that had occurred abroad between 2012 and 2014.^14351435 Martin {Day252/114:6}-{Day252/115:4}. For example, he did recall the fire at the Lacrosse building in Melbourne in November 2014, but said that he had only limited information about it at the time.^14361436 Martin {Day252/114:9-14}; {Day252/115:10-14}. None of those fires appears to have led to anything more than brief conversations with his former colleagues at BRE,^14371437 Martin {Day252/117:21}-{Day252/118:6}. though he appears to have had no discussions about them at all with Mr Harral, to whom by January 2014 he reported within the department.^14381438 Harral {Day244/79:12}-{Day244/80:25}. His knowledge of the use of aluminium composite panels with polyethylene cores in other countries and the fires associated with them did not cause Mr Martin to ask himself whether similar materials might be in use in this country.^14391439 Martin {Day252/118:22-24}. It did not occur to him that uncertainty about the meaning of paragraph 12.7 of Approved Document B might have led some designers, contractors and building control officers to accept the use of materials that were dangerous and did not consider that to be a major problem.^14401440 Martin {Day252/193:11-18}.

¶11.14 Equally, Mr Martin had made no connection at the time between the use of aluminium composite panels with polyethylene cores and the large-scale test carried out on a system incorporating similar material under contract cc1924 in 2001,^14411441 Martin {Day252/118:25}-{Day252/119:24}. See Chapter 7. even though Mr Baker had referred to those tests in the email he had sent to him asking about the meaning of paragraph 12.7 on 3 December 2013.^14421442 {CLG10005895/1}. Mr Martin said that he had thought that at the time of the 2001 tests aluminium composite panels with polyethylene cores were new products, not generally in use in the UK construction industry, and that if they had been in widespread use at the time of the test they would not have continued to be used following it.^14431443 Martin {Day252/120:14-18}. However, it is difficult to understand how he could have thought that, given that the results of those tests were not published until many years later.

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February 2014: Wintech's intervention

¶11.15 On 7 February 2014, Chris Macey, a director^14441444 Macey {WIN00000005/1} page 1, paragraph 1. of Wintech Ltd, a façade and engineering consultancy,^14451445 Taylor {WIN00000002/1} page 1, paragraph 1. contacted the department by email to express concern about the use of combustible insulation in high-rise buildings. He also drew attention to what he saw as a conflict between the guidance in Approved Document B on the use of insulation materials in the external walls of high-rise buildings and the requirement in Part L of Schedule 1 to the Building Regulations^14461446 Part L and Approved Document L, Conservation of Fuel and Power, set standards for energy efficiency in new and existing buildings. to make reasonable provision for the conservation of fuel and power by limiting heat loss through the fabric of buildings.^14471447 {CLG10006010/2-3}. In an email to Paul Decort, an official in the Building Regulations Division leading on sustainability,^14481448 Martin {Day253/31:24}-{Day253/32:4}. that was sent on to Brian Martin on 10 February 2014 Mr Macey warned that a number of major developers, contractors and manufacturers were ignoring the requirements of Part B^14491449 {CLG10006010/3}. and asked for a meeting with officials to discuss the matter.^14501450 {CLG10006010/3}. Within twenty minutes of receiving the email, however, Mr Martin had decided that there was no need to pursue the matter.^14511451 {CLG10006010/2}.

¶11.16 Mr Martin said that the department had neither the resources nor the authority to carry out an investigation of the kind suggested by Mr Macey.^14521452 Martin {Day253/42:12-15}; {Day253/44:9-11}. At any rate, he did not give any consideration to a potential conflict between the provisions of Parts B and L of Schedule 1 to the Building Regulations^14531453 Martin {Day253/41:13-16}. and did not ask Mr Macey for further information about the practices he had referred to.^14541454 Martin {Day253/42:16-24}. Indeed, it appears that he did not respond in any way to Mr Macey's message.^14551455 Macey {WIN00000005/35} page 35, paragraph 111.

April 2014: discussions with BRE

¶11.17 On 24 April 2014 Mr Martin received an invitation by email^14561456 {CLG00031072}. from Brenda Apted^14571457 Brenda Apted was the Centre for Window and Cladding Technology's office manager: Metcalfe {Day228/47:17-18}. of the Centre for Window and Cladding Technology (CWCT)^14581458 The Centre for Window and Cladding Technology is a not-for-profit research and technical organisation formed in the 1980s. The organisation produces guidance and training materials on various aspects of facades with the aim of improving standards in the façade industry: Metcalfe {Day228/4:4-24}; Metcalfe {CWCT0000115/2} page 2, paragraphs 6-8. to attend a meeting to discuss various aspects of fire and facades. In her message, she explained that the CWCT had recently received a number of inquiries, including about the use of combustible insulation in rainscreen facades and the fire performance of aluminium composite rainscreen materials. One of the topics for discussion at the meeting was to be the adequacy of the existing regulations. Mr Martin suggested that Dr Colwell might be interested and said he would assist where he could. He copied her into his reply.^14591459 {CLG00031072/1}.

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¶11.18 On 24 April 2014^14601460 {BRE00047459/2}. Brenda Apted sent an email to Dr Colwell inviting her to the meeting. Dr Colwell sent it on to Dr Debbie Smith and others in BRE, including Mr Baker and Stephen Howard.^14611461 In April 2014 Stephen Howard was business group manager for the BRE's Passive Fire Group: Howard {BRE00005771/2} page 2, paragraph 6. Dr Smith was clearly alarmed at the CWCT's involvement, which she saw as threatening BRE's pre-eminence in the field of fire safety.^14621462 {BRE00047459/1}. Indeed, she referred in the same internal email chain to the CWCT as a potential threat.^14631463 {BRE00047459/1}. Dr Smith said she could not remember why she had reacted in that way,^14641464 Smith {Day237/50:3-4}; {Day237/50:22}-{Day237/51:3}; {Day237/56:15}; {Day237/58:8-21}. but it is clear that her primary concern at the time was a desire to protect BRE's commercial position. It is equally clear both from that internal BRE email correspondence^14651465 {BRE00047459/2} "This is something we need to be aware of and should consider being involved with because of the increasing number issues (sic), similar to those identified below, which we are being asked by industry"; {BRE00047459/1} "The problem is now the issues we are seeing in the industry…". and from Dr Colwell's evidence,^14661466 Colwell {Day233/172:19}-{Day233/173:13}. that BRE was continuing to receive questions from industry about the meaning and scope of paragraph 12.7 of Approved Document B.

2 July 2014: the CWCT meeting

¶11.19 The meeting of the CWCT's Fire Group took place on 2 July 2014. Dr Colwell attended, as did Brian Martin, David Metcalfe and Alan Keiller of the CWCT, Chris Mort of Siderise, Ivor Meredith of Kingspan and others from across the industry and various interested associations.^14671467 For a full list of those who attended, see {CLG00019336/1}. Mr Martin was present for only part of the meeting,^14681468 CWCT Fire Group Minutes of Meeting dated 2 July 2014 {CLG00019336/4} third paragraph. but he did receive the minutes^14691469 Martin {CLG00019469/41} page 41, paragraph 119. and read them.^14701470 Martin {Day253/51:7-14}. They recorded discussions about two important matters: the use of aluminium composite material on high-rise buildings and the relationship between limited combustibility and Class 0.

¶11.20 At the meeting discussions proceeded on the common understanding that aluminium composite material normally consisted of two skins of aluminium separated by a polyethylene core and generally obtained a national Class 0 or Euroclass B classification. That was referred to as "the normal material". It was recognised that there had been several cladding fires in various countries where such material had been responsible for external fire spread.^14711471 CWCT Fire Group Minutes of Meeting dated 2 July 2014 {CLG00019336/3} under the heading "Use of ACM on high rise buildings". Someone appears to have said that paragraph 12.7 of Approved Document B was intended to prohibit the use of such material in buildings over 18 metres in height because it was not of limited combustibility, but that the wording did not make that clear, particularly because the heading referred to insulation materials and products. It was accepted that the expression "filler materials" could refer to the core but it was thought that that was not clear either.^14721472 CWCT Fire Group Minutes of Meeting dated 2 July 2014 {CLG00019336/4} second paragraph.

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¶11.21 Mr Martin was not present for that part of the meeting.^14731473 Martin {CLG00019469/41-42} pages 41-42, paragraph 119(c); Martin {Day253/63:6-8}; Metcalfe {Day228/81:12-18}. When he read the minutes, it did not occur to him that the reference to "the normal material"^14741474 CWCT Fire Group Minutes of Meeting dated 2 July 2014 {CLG00019336/3} penultimate paragraph. might indicate that it was being used widely in this country,^14751475 Martin {Day253/54:6-16}; Metcalfe {Day228/82:2-18}. or, for that matter, in any other part of the world.^14761476 Martin {Day253/54:17-22}. All he understood from that part of the minutes was that different types of aluminium composite panels were available in this country.^14771477 Martin {Day253/55:9-10}. Despite the heading of that paragraph ("Use of ACM on high rise buildings"),^14781478 CWCT Fire Group Minutes of Meeting dated 2 July 2014 {CLG00019336/3}. Mr Martin said that he had not realised that aluminium cladding panels with combustible cores might be in use on high-rise buildings in this country.^14791479 Martin {Day253/55:24}-{Day253/56:1}.

¶11.22 Mr Martin noted that at least one person present had, in his view, correctly understood that the word "filler" had been intended to prohibit the use of aluminium composite panels with polyethylene cores on high-rise buildings,^14801480 CWCT Fire Group Minutes of Meeting dated 2 July 2014 {CLG00019336/4} second paragraph. but that was to ignore both the fact that wording of paragraph 12.7 was not thought to be clear^14811481 CWCT Fire Group Minutes of Meeting dated 2 July 2014 {CLG00019336/4} second paragraph. and also the fact that the minutes referred to another possible interpretation of the clause, namely, that the word "filler" applied to all materials other than those specifically excluded, i.e. gaskets and sealants, and therefore included breather membranes.^14821482 CWCT Fire Group Minutes of Meeting dated 2 July 2014 {CLG00019336/4} first paragraph under the heading "Breather membranes"; Martin {Day253/78:12}-{Day253/79:16}.

¶11.23 Mr Martin did not know who had put forward what he regarded as the correct interpretation of the expression "filler material" and did not take any steps to find out.^14831483 Martin {Day253/100:9-21}. It did not occur to him that others at the meeting might have disagreed with that interpretation or that it might have been new to them^14841484 Martin {Day253/102:21}-{Day253/103:11}. and was not concerned by the fact that the matter was being debated by a group of professionals seven years after the publication of the text.^14851485 Martin {Day253/102:13-20}. He said that until he read the minutes of the meeting in July 2014 it had not crossed his mind that the use of the word "insulation" in the heading of paragraph 12.7^14861486 {CLG10000005/99}. might lead readers to think that the paragraph was directed specifically to insulation.^14871487 Martin {Day253/104:1-12}. We find that hard to believe.

¶11.24 A number of building professionals who had attended the meeting said that they had been surprised by the suggestion that the word "filler" in paragraph 12.7 had been intended to apply to the core of a composite cladding panel,^14881488 Taylor {WIN00000002/56} page 56, paragraphs 126-127. We note that Stuart Taylor, Technical Director at Wintech, having read paragraph 12.7 and been unsure of its intended meaning, had checked the matter with Dr Colwell shortly after the publication of the 2007 edition of Approved Document B and that it was her advice that formed the basis of his understanding of the meaning and scope of the paragraph.Show full note which did not accord with their own understandings of the provision.^14891489 Metcalfe {CWCT0000115/10-12} pages 10-12, paragraphs 36, 40 and 41; Metcalfe {Day228/90:1-5}; {Day228/91:3-12}; Hepworth {LMD00000001/1} page 1, paragraph 2(b); Rowan {AFP00000002/4-16} pages 4-16 and page 16, paragraphs 2(b)-(d) and paragraph 7(d). David Metcalfe could not recall anyone else at the meeting agreeing^14901490 Metcalfe {Day228/91:13-15}. with what Mr Martin considered to be the correct interpretation of paragraph 12.7,^14911491 Metcalfe {CWCT0000115/11} page 11, paragraph 40. which he and others said had been put forward by Dr Colwell.^14921492 Metcalfe {CWCT0000115/10} page 10, paragraph 36; Hepworth {LMD00000001/5} page 5, paragraph 7(a); Taylor {WIN00000002/73} page 73, paragraph 175. See also Colwell {Day233/199:16}-{Day233/200:5}; Martin {Day253/101:21}-{Day253/102:7}. Mr Metcalfe also said that he could not recall having spoken to any construction professional who thought that paragraph 12.7 applied to anything other than insulation.^14931493 Metcalfe {CWCT0000115/11} page 11, paragraph 40. Mr Martin made no attempt following the meeting to find out whether aluminium composite panels with combustible cores had been or were currently being installed on high-rise buildings in this country.^14941494 Martin {Day253/54:23}-{Day253/55:2}; {Day253/67:19-24}. It seems that he did not pay a great deal of attention to the minutes at the time.^14951495 Martin {Day253/59:19-20}.

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¶11.25 During the discussion someone suggested that the meaning and scope of paragraph 12.7 of Approved Document B could be clarified by the publication of an FAQ on the department's website and Dr Colwell agreed to raise the matter with Mr Martin.^14961496 CWCT Fire Group Minutes of Meeting dated 2 July 2014 {CLG00019336/4} third paragraph. In the event, she failed to do so in circumstances we describe below. Nonetheless, when no draft arrived, Mr Martin did not take the matter up with her.^14971497 Martin {Day253/121:21}-{Day253/122:3}. In effect, he forgot about it^14981498 Martin {Day253/121:24}-{Day253/122:3}; {Day253/126:7-16}. and as a result the department did not consider publishing any clarification of paragraph 12.7 before the fire at Grenfell Tower.^14991499 Martin {Day253/120:22}-{Day253/121:2}.

Brian Martin's reaction

¶11.26 Brian Martin told us that he had not deliberately ignored the significance or seriousness of the possible use of ACM panels on the external walls of high-rise buildings or the uncertainty within some sections of the construction industry about the meaning of paragraph 12.7,^15001500 Martin {Day253/58:22-23}; {Day253/59:3-6}; {Day253/59:10-20}; {Day253/62:11-12}; {Day253/65:7-12}; {Day253/64:3-8}; {Day253/65:8-12}; {Day253/66:20-25}; {Day253/68:7-9}; {Day253/104:21}-{Day253/105:4}; {Day253/132:9-21}. but that he had underestimated their importance.^15011501 Martin {Day253/112:9-17}. He also failed to make a connection between the matters under discussion and the test that had been carried out some years earlier using aluminium composite panels under contract cc1924. He did not discuss what had been said at the CWCT meeting or the contents of the minutes with Mr Harral or Mr Ledsome^15021502 Martin {Day253/62:8-12}; {Day253/116:16-19}; Harral {Day244/77:8-13}; {Day244/84:21-23}; Ledsome {Day241/208:1-7}; {Day242/195:10-12}; {Day242/198:11-15}; {Day242/200:14}-{Day242/201:1}. because he saw no need to do so.^15031503 Martin {Day253/116:24}. Neither of them was made aware, therefore, that members of the CWCT's fire group were all of the view that the meaning of paragraph 12.7 of Approved Document B was unclear.^15041504 Ledsome {Day242/200:14-18}; Harral {Day244/81:23}-{Day244/82:13}; Martin {Day253/131:20}-{Day253/132:7}. In our view Mr Martin should have taken the matter more seriously and should at least have informed his immediate superiors that there was a problem that required attention.

¶11.27 We find it difficult to understand why Mr Martin did not appreciate the significance of the discussions or the potential consequences of the use of ACM panels for the safety of those living in high-rise buildings. If he saw the discussion as an opportunity to improve compliance,^15051505 Martin {Day253/68:7-9}. it is surprising that he took no steps to clarify the guidance. His failure to alert more senior officials in the department to the discussions fell short of the response that could be expected of the person with day-to-day responsibility for the Building Regulations and Approved Document B.

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Dr Colwell and the FAQ

¶11.28 Although at the CWCT meeting on 2 July 2014 Dr Colwell had said that she would speak to Brian Martin about the publication of an FAQ to clarify the meaning of paragraph 12.7, in the event she failed to do so.^15061506 Colwell {Day233/204:3-8}. After the meeting she tried to draft something suitable^15071507 Colwell {Day233/205:13-15}; {Day233/218:13-19}; {Day233/219:17}-{Day233/220:7}. but in discussions with her colleagues, including Dr Smith,^15081508 Colwell {Day233/205:21}-{Day233/206:4}. she formed the view that, if there was going to be a review of Approved Document B in the near future, it would be better to deal with the matter as part of that review.^15091509 Colwell {Day233/204:9-18}. By August or September 2014^15101510 Colwell {Day233/206:23}-{Day233/207:7}. Dr Colwell and Dr Smith had reached a decision not to produce a draft FAQ for consideration by Mr Martin,^15111511 Colwell {Day234/27:21}-{Day234/28:5}. but Dr Colwell did not tell him of that. She and her colleagues knew that he had received the minutes of the meeting and knew that he was aware that the work needed to be done, so they decided not to pursue it.^15121512 Colwell {Day233/221:25}-{Day233/222:12}. None of the others who had attended the meeting on 2 July 2014 were told about the decision not to draft an FAQ .^15131513 Colwell {Day233/206:18-21}; {Day234/13:9-19}. The CWCT had thought that a draft would be produced quickly^15141514 Metcalfe {Day228/115:17-18}; {Day228/116:6-7}; {Day228/116:19-23}; {Day228/117:24}-{Day228/118:2}; {Day228/137:1-5}; {CWCT0000040/2}. and was waiting for Dr Colwell to provide it, while growing increasingly frustrated as the months passed.^15151515 Metcalfe {Day228/120:12}-{Day228/121:2}; {Day228/121:9-13}; {Day228/141:11-12}; {Day228/142:11}-{Day228/143:3}; {Day228/148:6-18}. It seems that she did not regard it as a matter of much importance, either.

¶11.29 That is perhaps surprising, because Dr Colwell had been well aware of the startling results of the test carried out on aluminium composite panels under contract cc1924.^15161516 Colwell {Day232/97:21-23}. The product had been offered to BRE for testing under that programme because the extent of its use made testing of interest to the construction industry.^15171517 Colwell {Day232/95:14}-{Day232/96:11}. In addition, she had been engaged in recent work on cladding fires with authorities in the United Arab Emirates following fires involving the same kind of material.^15181518 Colwell {Day233/208:18}-{Day233/210:10}. She could therefore not have been unaware of the risk to life its use on high-rise buildings presented in the event of fire. Having said that she would produce a draft FAQ, it is therefore hard to see why she did nothing at all, even if she and others at BRE had not realised at the time that aluminium composite panels were already being used on high-rise buildings in this country.^15191519 Colwell {Day233/213:5-10}. Dr Colwell had a longstanding professional relationship with Brian Martin and could have pursued the matter with him at any time. She could at least have told him that BRE would not be providing a draft.

¶11.30 In fact, Dr Colwell misled the CWCT about the preparation of a draft FAQ. She did not respond^15201520 Colwell {Day234/7:9-13}. to an email from Stuart Taylor of Wintech on 7 July 2014 which referred to "great confusion" about the meaning of paragraph 12.7 and to her agreement to draft an FAQ to clarify it.^15211521 {BRE00016101/2}. Dr Colwell, together with Stephen Howard and possibly Mr Baker,^15221522 Colwell {Day234/10:6-10}; Taylor {WIN00000002/84} page 84, paragraph 203; Colwell {Day234/10:24}-{Day234/11:1}. met Mr Taylor and Alan Keiller of the CWCT on 8 September 2014 to discuss the matter.^15231523 Keiller {CWCT0000119/7} page 7, paragraph 25; Colwell {Day234/10:3-5}; Taylor {WIN00000002/84} page 84, paragraph 203. Inexplicably, although by the date of that meeting BRE was having second thoughts about producing a draft,^15241524 Colwell {Day234/12:16}-{Day234/13:2}. she did not tell anyone else that. Mr Keiller's recollection was that it had been agreed that the matter would be dealt with by way of an FAQ.^15251525 Keiller {CWCT0000119/7} page 7, paragraph 26. Mr Taylor recalled the same outcome, specifically that BRE had confirmed that it would prepare some draft wording.^15261526 Taylor {WIN00000002/84} page 84, paragraph 204(10).

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¶11.31 However, after the meeting Dr Colwell simply did nothing. As late as 13 March 2015, five months after she and Dr Smith had decided that BRE would not produce a draft FAQ, she sent a brief response to an email from David Metcalfe asking about progress,^15271527 {CWCT0000040/2}. in which she referred to a note that she said would be finished soon and circulated so that others could comment on it.^15281528 {CWCT0000040/1}. Dr Colwell told us that that was a reference to some draft wording for a revised version of Approved Document B, not for an FAQ,^15291529 Colwell {Day234/18:16-20}; {Day234/19:8-10}. but we are not convinced that that was how it was intended to be understood. After that exchange, Dr Colwell failed to reply to five further emails from Mr Metcalfe.^15301530 {CWCT0000116}; Metcalfe {CWCT0000115/14} page 14, paragraph 48; Metcalfe {Day228/146:16-19}; Colwell {Day234/22:9}-{Day234/23:2}. She had no real explanation for that^15311531 Colwell {Day234/19:12-15}; {Day234/22:6-8}. and accepted that she should have responded to them.^15321532 Colwell {Day234/23:9-14}.

A missed opportunity to clarify Approved Document B

¶11.32 In our view, in the absence of any draft from Dr Colwell Mr Martin could and should have taken action himself. If, as he told us, the words "filler material" had been added to paragraph 12.7 to restrict the use of cladding panels with combustible cores on buildings over 18 metres in height,^15331533 See Chapter 7. that was a good reason for him to take careful note and at the very least to have reported to Mr Harral the fact that there was disagreement about its meaning. The CWCT meeting on 2 July 2014 should have prompted him to find out how paragraph 12.7 was understood. He told us that he wished he had done that but that he had not thought of it at the time.^15341534 Martin {Day253/84:13-21}.

¶11.33 The discussion at the CWCT meeting had produced some important information,^15351535 Harral {Day244/82:19-23}. both because it showed that the meaning of paragraph 12.7 was unclear to many and because the material being discussed had been linked to a series of major fires.^15361536 Harral {Day244/84:8-12}. Mr Martin should have reported the problem to Mr Harral,^15371537 Harral {Day244/82:14-18}; {Day244/84:18-20}. which would have prompted a serious discussion about whether to refer it to more senior officials or the minister.^15381538 Harral {Day244/84:24}-{Day244/85:6}. Mr Martin, Mr Harral and Mr Ledsome all thought that an FAQ could have been published without any particular difficulty,^15391539 Martin {Day253/125:9}-{Day253/126:6}; Harral {Day244/43:3-18}; {Day244/86:4}-{Day244/87:3}; Ledsome {Day242/204:14-25}. although it would have to be approved by the department's lawyers and political advisers. Mr Ledsome also said that in an appropriate case a definition could be added to the glossary attached to Approved Document B.^15401540 Ledsome {Day242/191:11-25}. It was the task of Mr Martin, as the official with primary responsibility for that area of policy, to assess the nature and urgency of the problem and decide whether an FAQ was justified.^15411541 Harral {Day244/42:19}-{Day244/43:7}; {Day244/45:2-8}; Ledsome {Day242/159:3-11}; {Day242/160:8-14}. If he thought it was, he should have raised it with Mr Harral or Mr Ledsome.^15421542 Ledsome {Day245/30:2-4}; Ledsome {Day242/196:3-5}; Harral {Day244/87:12-15}. There was no formal process for doing that, even if he considered the matter to be urgent.^15431543 Harral {Day244/44:25}-{Day244/45:8}; {Day244/54:11}-{Day244/55:14}; {Day244/111:7-23}; Ledsome {Day242/195:22}-{Day242/196:5}. In the event, however, the question of producing an FAQ did not arise because Dr Colwell failed to provide a draft for Mr Martin's consideration and Mr Martin did not act on his own initiative.

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¶11.34 Neither Mr Harral nor Mr Ledsome was aware of questions or concerns raised with Mr Martin unless he chose to tell them,^15441544 Martin {Day253/132:22}-{Day253/133:3}. which, since he was responsible for matters affecting the safety of life, was unsatisfactory and potentially dangerous. In our view a more senior official, probably Mr Ledsome, should have obtained regular reports from Mr Martin about current developments in the construction industry and the way in which the Building Regulations and guidance were operating. The absence of a reporting system created an obvious risk that a single busy official might either overlook the importance of something or simply fail to act on it. Although we think that in July 2014 Mr Martin should have drawn the minutes of the meeting on 2 July 2014 to the attention of Mr Harral and Mr Ledsome, the department's awareness or otherwise of a serious risk to public safety should not have depended on whether one official recognised it and acted appropriately upon it.

The confusion between Class 0 and limited combustibility

¶11.35 The second important subject of discussion at the CWCT meeting on 2 July 2014 was the relationship between limited combustibility and Class 0. Paragraph 12.7 of Approved Document B said that only insulation materials of limited combustibility should be used in the external walls of buildings over 18 metres in height, but some of those present said that other materials, principally foil-faced phenolic foam, were often used in rainscreen constructions. It seems to have been accepted that in some cases, probably through ignorance, some people were confusing Class 0 with limited combustibility. In other cases, building control officers were permitting the use of Class 0 materials, making it difficult for cladding consultants to insist on the use of insulation of limited combustibility.^15451545 CWCT Fire Group Minutes of Meeting dated 2 July 2014 {CLG00019336/3} under the heading "Combustibility of insulation". Mr Martin was present during that discussion^15461546 Martin {Day253/134:4-6}; Martin {CLG00019469/42} page 42, paragraph 120. and had sent an email to NHBC on that very subject earlier that day.^15471547 {NHB00000712/3}.

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¶11.36 That appears to have been the first time that Mr Martin had become aware of any confusion between limited combustibility and national Class 0^15481548 Martin {Day253/135:15}-{Day253/136:1}. or that anyone could consider that polymer foam was a material of limited combustibility,^15491549 Martin {Day253/136:25}-{Day253/137:9}. which he regarded as implausible.^15501550 Martin {Day253/136:22-24}. He was surprised^15511551 Martin {Day253/136:2-3}. and concerned^15521552 Martin {Day253/136:22}. by both, but he did not ask any of those who attended the meeting for further information.^15531553 Martin {Day253/138:16-22}. Mr Martin had recently attended a meeting at Arup Fire on 25 June 2014 to discuss fire and facades, including the use of combustible materials.^15541554 {CLG00031777}. The discussion had touched on the definitions of non-combustibility and limited combustibility^15551555 Smith {Day237/74:7-10}. and there may also have been some discussion about the use of combustible insulation in the external walls of buildings over 18 metres in height.^15561556 Smith {Day237/76:21-25}.

2 July 2014: Brian Martin's friendly warning

¶11.37 The matters discussed at that meeting may have been the catalyst for the email Brian Martin sent to Neil Smith of NHBC on 2 July 2014.^15571557 Martin {Day253/147:2-10}; {Day253/147:24}-{Day253/148:4}. He described the purpose of the email as a "friendly warning" and told Mr Smith that he had heard from relatively reliable sources that buildings over 18 metres in height, including blocks of flats, had been clad in PIR (polyisocyanurate) insulation on the basis of an erroneous view that such insulation was a material of limited combustibility. He asked Mr Smith to check the matter with his inspectors.^15581558 {NHB00000712/3}. Mr Martin told us that in sending that message he had been fishing for information;^15591559 Martin {Day253/150:16-19}. he had not known at the time whether combustible insulation was being widely used in a way that did not comply with Approved Document B.^15601560 Martin {Day253/156:20}-{Day253/157:1}. NHBC's carefully considered response, which was sent by Steve Evans on 11 July 2014,^15611561 As to which, see Chapter 26. confirmed that that was the case and that NHBC had been in discussion with industry, in particular Kingspan, about the use of Kooltherm K15 on high-rise buildings for some time.^15621562 {CLG00000686}. That came as a surprise to Mr Martin.^15631563 Martin {Day253/157:7-8}.

NHBC's response

¶11.38 When he responded, Mr Evans informed Brian Martin of a number of important matters. First, he told him that Kingspan was asserting that K15, a combustible phenolic foam insulation material,^15641564 See Chapter 26. was suitable for use on buildings over 18 metres in height. Secondly, he said that since 27 October 2008, K15 had held a BBA certificate stating that it was acceptable for use in accordance with paragraph 12.7 of Approved Document B, subject only to advice being sought from Kingspan for use on buildings over 18 metres in height.^15651565 That was not correct. The original BBA certificate, issued on 27 October 2008 {BBA00000038}, contained no reference to the use of K15 in accordance with paragraph 12.7 of Approved Document B. That wording was first introduced in Amended Issue 1, dated 6 April 2010 {BBA00000037}. It was on the basis of that BBA certificate, he said, that NHBC inspectors had been accepting K15 for use on high-rise buildings, including blocks of flats. Mr Evans also mentioned in his email that there existed an LABC Registered Details Certificate for K15 approving the material for use in the external walls of buildings over 18 metres in height.^15661566 {CLG00000686/1}.

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¶11.39 Mr Evans also said that a revised BBA certificate for K15 dated 17 December 2013 did not refer to paragraph 12.7 of Approved Document B. Instead, it stated that K15 had been tested for use in the external walls of buildings over 18 metres in height only in one particular construction on masonry walls.^15671567 {CLG00000686/1}. Mr Evans attached both the previous^15681568 {CLG00000688}. and the (then) current BBA certificates to his email.^15691569 {CLG00000687}. He said that NHBC had approached Kingspan which was in the process of carrying out further tests, the results of which were expected at the beginning of August 2014.^15701570 {CLG00000686/1}. Mr Evans also said that if those tests did not prove that K15 was suitable for use on buildings over 18 metres in height on anything other than the one masonry system tested to BS 8414, NHBC planned to tell the industry and others who were interested that it was no longer suitable for use on high-rise buildings.

¶11.40 Thirdly, Mr Evans assured Mr Martin that there was no reason to suspect that buildings that had been built with Kingspan K15 were at risk at that time.^15711571 {CLG00000686/2}. That statement was clearly wrong, as Mr Martin, Mr Harral and Mr Ledsome should have realised immediately. It betrayed a fundamental misunderstanding of the purpose and nature of the regulations and guidance. It was quite wrong to suggest that a widespread failure to comply with the guidance on fire safety created no risk simply because future tests might show that none existed. On the contrary, without test evidence to show that K15 could be used safely in the external walls of high-rise buildings, there was every reason to suspect the existence of a real and immediate risk and every reason to take action.

The department's reaction

¶11.41 Concerned that there might be a significant problem,^15721572 Martin {Day253/167:24}-{Day253/168:1}; Martin {CLG00019469/43} page 43, paragraph 124. Mr Martin sent the email from Mr Evans on to Richard Harral and Bob Ledsome on the same day with the comment that "If it is a problem, some blocks may need to have their cladding replaced. (possibly a lot of them)".^15731573 {CLG00000686/1}. Having discussed the matter, they decided that the best course was to wait and see what NHBC found out.^15741574 Martin {Day253/187:12-15}; {Day253/188:10-12}; {Day253/190:22}-{Day253/191:6}; {Day253/192:23}; {Day253/193:5-6}; {Day254/14:13-18}; {Day254/16:12-25}; {Day253/213:11-12}; Martin {CLG00019469/43} page 43, paragraph 124; Ledsome {CLG00019465/57} page 57, paragraph 220; Ledsome {Day242/211:22}-{Day242/212:7}; Harral {Day244/93:4-11}. They did not decide how long they should wait;^15751575 Martin {Day253/191:7-10}; {Day253/193:7-11}. it seems that all three of them took some comfort from the assertion by NHBC that there was probably no real risk^15761576 Martin {Day253/179:11-17}; {Day253/189:20-21}. and that Kingspan's testing would resolve the problem.^15771577 Martin {Day253/173:19-21}; {Day253/180:1-3}. Mr Martin thought it possible that the question might be academic rather than represent a genuine safety problem.^15781578 Martin {Day253/190:4-10}.

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Contact with the BBA

¶11.42 The only action the department itself took in relation to the matter was to contact John Albon at the BBA. In an email to Mr Albon, sent on the day he received the message from Mr Evans, Mr Martin asked him to find out how the previous BBA certificate had stated that K15 satisfied paragraph 12.7 of Approved Document B, which he described as a "serious safety matter".^15791579 {BBA00000178/3}. When Mr Albon responded on 16 July 2014, he told Mr Martin that the reference to paragraph 12.7 had been an unfortunate and rare oversight that had not been repeated in any other certificates.^15801580 {BBA00000178/2}. In response Mr Martin asked Mr Albon to summarise the systems the BBA had put in place to ensure that the error would not be repeated and to confirm whether or not the BBA had notified Kingspan of it.^15811581 {BBA00000178/2}.

¶11.43 Mr Albon's response on 23 July 2014 evaded the latter question, saying only that he expected that Kingspan would have been made aware of the matter. Mr Martin did not press for an answer, as he should have.^15821582 Martin {Day253/208:18}-{Day253/209:3}. Mr Albon went on to say that it was extremely unlikely that anyone had inferred from the wording of the 2010 revision of the certificate that K15 was a material of limited combustibility.^15831583 {BBA00000178/1}. As Mr Martin agreed, that was nonsense.^15841584 Martin {Day253/211:4-21}. It could not reasonably have meant anything else.^15851585 See Chapter 22. Nonetheless, the department did not pursue the matter with the BBA.^15861586 Martin {Day253/209:24}. Both Mr Martin and Mr Ledsome were satisfied with its assurances that the error had been an isolated occurrence.^15871587 Martin {CLG00019469/44} page 44, paragraph 126; Ledsome {CLG00019465/57-58} pages 57-58, paragraphs 221- 222; Ledsome {Day242/219:4-25}. It did not occur to Mr Martin to ask how such a fundamental error in a BBA certificate had come about.^15881588 Martin {Day253/206:22}-{Day253/207:20}. In our view he should have pursued the matter.

¶11.44 Mr Martin read the BBA certificates for K15 that Mr Evans had attached to his email on 11 July 2014,^15891589 Martin {Day253/166:2-8}. as did Mr Harral and Mr Ledsome.^15901590 Harral {Day244/89:10-15}; Ledsome {Day242/206:25}-{Day242/207:9}; Ledsome {Day245/3:21}-{Day245/4:6}. Mr Martin was concerned by the reference to paragraph 12.7 in the earlier certificate dated 6 April 2010.^15911591 Martin {Day253/167:22-24}. He accepted that he had realised immediately that the assertion that a combustible foam could be used in accordance with paragraph 12.7 was a fundamental error.^15921592 Martin {Day253/167:9-21}; {Day253/168:11-21}. However, he did not appear to be particularly alarmed, as we think he plainly should have been, by the fact that NHBC had not spotted that error and had considered itself to be bound by the contents of the certificate^15931593 Marshall {Day225/101:25}-{Day225/102:14}; Evans {NHB00003020/17} page 17, paragraph 52; Martin {Day253/196:13-20}. over the course of several years.

The department's omissions: K15

¶11.45 However many BS 8414 tests Kingspan planned to carry out in the future, they could never have established that K15 was generally suitable for use in the external walls of buildings over 18 metres in height, as Mr Martin accepted.^15941594 Martin {Day253/177:11-15}. Moreover, they could not establish that it was suitable for use on buildings already completed unless a replica of each system were subjected to large-scale testing. The department did not know how many of those buildings there were, because it did not ask and it did not occur to it to do so.^15951595 Martin {Day253/184:16-21}; {Day253/187:25}-{Day253/188:6}; Ledsome {Day245/10:24}-{Day245/11:4}; Martin {Day254/16:5-14}. Mr Martin presumed that there were a significant number of buildings affected, possibly about one hundred.^15961596 Martin {Day253/187:16-24}; {Day253/189:7-13}.

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¶11.46 Mr Ledsome's confidence that the NHBC had got a grip on the issue^15971597 Ledsome {Day245/7:20-25}. was wholly unjustified and we cannot accept that Mr Harral was right in thinking that the department had done all it could.^15981598 Harral {Day244/100:5-9}. Despite the fact that all three of them appeared to acknowledge that the matter was, at least potentially, a serious safety issue,^15991599 Harral {Day244/92:14-16}; {Day244/137:13-16}; Ledsome {Day242/211:4-6}; {BBA00000178/3}; Martin {Day253/167:24}-{Day253/168:1}; {Day253/198:24}-{Day253/199:11}. none of them referred it to anyone more senior.^16001600 Harral {Day244/92:17-19}; Ledsome {Day242/211:7-8}. They did not ask for advice or speak to anyone else about it.^16011601 Harral {Day244/100:14-22}; {Day244/138:22}-{Day244/139:2}. They took no steps to alert the industry to what they had learnt.^16021602 Ledsome {Day242/216:23}; Martin {Day253/153:1-18}. Mr Ledsome, who also managed a separate policy team that had oversight of the building control system,^16031603 Ledsome {Day245/20:19}-{Day245/21:3}. did not notify it that building control officers had been accepting a combustible insulation material as generally suitable for use on buildings over 18 metres in height for some considerable time.^16041604 Ledsome {Day245/21:25}-{Day245/22:5}.

¶11.47 Their omissions did not end there. They neither sought to obtain a copy of the LABC certificate to which Mr Evans had referred in his email nor contacted the LABC to find out how it had been possible to issue a certificate approving the use of a combustible insulation material in the external walls of buildings over 18 metres in height.^16051605 Martin {Day253/191:11}-{Day253/192:15}; {Day253/160:23}-{Day253/161:9}; Ledsome {Day245/14:6-14}; Harral {Day244/105:17-22}. That was despite the fact that in late 2009 Mr Martin had received two letters from Larry Cody of Rockwool alerting the department to that claim and to the fact that the certificate stated that K15 could be considered a material of limited combustibility.^16061606 {LABC0000924}; {LABC0000853}. Mr Martin could not recall having received those letters^16071607 Martin {Day253/159:5-8}; {Day253/160:6}; {Day253/163:3}. but said that, if he had read them, he would have considered the matter to be one for the LABC, Rockwool and Kingspan to deal with. In his view it was not the function of the department to police the system.^16081608 Martin {Day253/160:6}-{Day253/161:7}.

¶11.48 None of the officials warned any building control organisation, other than NHBC, against approving the use of K15 on high-rise buildings, even when it became clear from Mr Evans' response that other bodies had also been accepting it.^16091609 Harral {Day244/104:16-22}; Ledsome {Day242/209:24}-{Day242/211:3}; Martin {Day253/151:22}-{Day253/152:25}; {Day253/170:15-25}. Mr Martin thought that, as the largest building control organisation, NHBC was well-resourced^16101610 Martin {Day253/152:8-13}. and had taken the lead by talking to others, including the Building Control Alliance (BCA)^16111611 The BCA is a voluntary membership organisation, later incorporated as a limited company, established in 2008 to promote the role of building control organisations and to publish guidance: Evans {NHB00003020/59-60} pages 59‑60, paragraph 164. about it.^16121612 Martin {Day253/170:21}-{Day253/171:14}. However, he accepted that he should have contacted the LABC himself.^16131613 Martin {Day253/152:14-19}. Mr Harral had been under the impression that the problem was limited to NHBC,^16141614 Harral {Day244/91:23}-{Day244/92:8}. but that was plainly not the case. None of the three officials did anything to establish the location of the buildings affected or how many there were.^16151615 Ledsome {Day245/15:21}-{Day245/16:16}; {Day245/19:3-7}; Harral {Day244/105:23}-{Day244/106:1}; Martin {Day253/184:16}-{Day253/185:10}; {Day253/188:1-6}; {Day253/188:16-21}. They did not alert the Advertising Standards Agency or Trading Standards.^16161616 Harral {Day244/97:17-23}; Ledsome {Day245/9:9}-{Day245/10:3}. They did not contact Kingspan^16171617 Harral {Day244/97:9-11}; Ledsome {Day245/7:17-18}; Martin {Day253/192:16-21}. or examine its marketing literature.^16181618 Martin {Day253/210:24}-{Day253/211:3}; Harral {Day244/97:12-16}; Ledsome {Day245/8:3-6}. The department had assumed that Kingspan would act responsibly, but, as Mr Ledsome accepted, that had been rather naïve. Faced with evidence that a commercial organisation was relying on false statements to market its products, we think that the department should have taken steps to draw its activities to the appropriate authorities.

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¶11.49 None of the officials involved thought it necessary to alert the United Kingdom Accreditation Service (UKAS)^16191619 UKAS was established in 1995 to accredit conformity assessment bodies against national and international standards of technical competence to undertake certain activities, including certification: Turner {UKAS0011242/4‑5} pages 4-5, paragraph 7 (a)-(b). to the errors in the certificates issued by the BBA or to remind Mr Albon that the BBA ought to report the matter to UKAS itself. Mr Martin accepted that he should have reported the matter to UKAS,^16201620 Martin {Day253/202:5-20}; {Day253/207:17-23}. but he did not think at the time that it might uncover wider problems in the BBA's processes^16211621 Martin {Day253/202:16-20}. or that the failure by UKAS to identify the error was itself a matter of concern.^16221622 Martin {Day253/203:3-6}. It did not occur to him that there might be a similar problem in relation to insulation products other than K15.^16231623 Martin {Day254/14:10-25}.

¶11.50 Mr Martin did not take any steps to pursue the matter following his email exchange with Mr Evans. On 15 August 2014^16241624 {CLG00019253}. Mr Evans reported that Kingspan had been encouraged by the preliminary results of two large-scale tests involving K15 but gave no results. He said that Kingspan had asked Arup to prepare a desktop report using the results from the three tests it had by then carried out under BS 8414 to describe the conditions that any cladding system should meet to allow K15 to be used in the construction of external walls of buildings over 18 metres in height.^16251625 {CLG00019253/1}. In the event, however, no such report was forthcoming^16261626 Martin {Day254/11:25}-{Day254/12:2}. and it is difficult to see on what basis Mr Martin could have thought that that might be a satisfactory method of assessing the suitability of K15 for use on high-rise buildings.^16271627 Martin {CLG00019469/45} page 45, paragraph 128; Martin {Day254/7:15}-{Day254/8:7}; {Day254/10:4}-{Day254/11:9}. As far as he was aware, in August 2014 there was no satisfactory test data to support the use of K15 on high-rise buildings.^16281628 Martin {Day254/13:25}-{Day254/14:25}. Nonetheless, he said that, having discussed the matter further with Mr Ledsome,^16291629 Martin {Day254/17:1-18}. they had concluded that the best course was simply to wait and see how the matter developed.^16301630 Martin {Day254/17:24}-{Day254/18:1}.

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¶11.51 In the event, Brian Martin did nothing further until 4 December 2014, when he sent an email to Mr Evans asking whether NHBC had any further information.^16311631 {CLG00019264/1-2}. On 5 December 2014, Mr Evans said that he should be able to respond after a BCA meeting the following Monday,^16321632 {CLG00019264/1}. but in the event he failed to do so^16331633 Martin {Day254/26:23}-{Day254/27:1}. and Mr Martin let the matter lie. There was no further contact between NHBC and the department until 2 April 2015,^16341634 Martin {Day254/28:3-17}. when Mr Evans sent an email to Mr Martin simply telling him that Kingspan was committed to further testing. It does not appear to have occurred to Mr Martin to ask for existing test results or the desktop report that was to be produced by Arup.^16351635 Martin {Day254/70:7-12}. It was clear to Mr Martin at that stage that the problem relating to the use of combustible insulation on high-rise buildings had not been resolved.^16361636 {NHB00001057}.

¶11.52 No reasonable excuse was offered for that remarkable list of omissions. Mr Martin appears simply to have allowed himself to be guided by NHBC, which had in turn been taken in by Kingspan's repeated assurances that further testing would demonstrate that all was well.^16371637 Martin {Day253/179:10-23}; {Day253/180:1-3}; {Day253/182:20}-{Day253/183:5}. Although he had been told by Mr Evans that NHBC's inspectors had been accepting K15 for use on buildings over 18 metres in height for many years, it did not occur to Mr Martin that NHBC might have its own reasons for seeking to demonstrate that K15 was suitable for use on high-rise buildings.^16381638 Martin {Day254/25:22}-{Day254/26:17}. Although they had been sent to Mr Harral,^16391639 {CLG10006884}; Harral {Day244/113:24}-{Day244/114:23}. neither he nor Mr Martin had had time to read the notes^16401640 Martin {Day254/21:21-23}; {Day254/23:4-5}; {Day254/24:7-8}. of a BCA meeting on 8 December 2014 which appeared to suggest that both NHBC and the LABC in the persons of Steve Evans and Barry Turner were doing exactly that.^16411641 {CLG10006889/4} section 12.0. Mr Martin regarded the people he knew at NHBC as responsible professionals; he trusted them and did not question their motives.^16421642 Martin {Day254/26:12-22}.

¶11.53 We accept that the department was ill-equipped to investigate the use of combustible insulation on high-rise buildings^16431643 Harral {Day244/98:1-2}; Martin {Day253/42:12-15}. and was busy with other work.^16441644 Harral {Day244/76:23}-{Day244/77:4}; {Day244/98:1-6}; {Day244/103:3-7}; Martin {Day253/171:15-21}; Martin {Day254/12:10-13}; {Day254/28:16-22}; {Day254/29:8-10}. It was not responsible for enforcing the Building Regulations, had limited power to intervene in operations and had a negligible role^16451645 Harral {Day244/36:2-6}. in the direct regulation of the industry. That was the responsibility of the building control bodies and the department left it to industry bodies to resolve any problems that might arise.^16461646 Ledsome {CLG00019465/57} page 57, paragraph 221; Ledsome {Day245/22:10}-{Day245/23:20}; {Day245/24:25}-{Day245/26:5}; Harral {CLG00019487/17} page 17, paragraph 56; Harral {Day244/35:22}-{Day244/36:21}; {Day244/93:4-11}; {Day244/98:6}-{Day244/99:13}; {Day244/99:24}-{Day244/100:13}; {Day244/101:3-19}; {Day244/103:7-14}; {Day244/109:2-8}; Martin {CLG00019469/38} page 38, paragraph 113; Martin {Day253/151:14‑19}; {Day253/161:22}-{Day245:162:14}; {Day253/171:9-14}; {Day254/15:12}-{Day254/16:4}.Show full note However, that does not justify its failure to act on what it knew and indeed, as all three officials accepted during their evidence, more could and should have been done.^16471647 Harral {Day244/107:2-11}; {Day244/99:14}-{Day244/100:13}; {Day244/103:22}-{Day244/104:8}; Ledsome {Day245/9:22}-{Day245/10:3}; {Day245/10:24}-{Day245/11:5}; {Day245/13:10-16}; {Day245/14:15-24}; {Day245/17:8}-{Day245/18:22}; {Day245/23:21}-{Day245/24:19}; {Day245/25:20-25}; Martin {Day254/29:8-10}; {Day254/71:3-10}. The department's failure to act was a serious error.

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August 2014: BCA Technical Guidance Note 18

¶11.54 On 15 August 2014 Brian Martin received from Steve Evans^16481648 {CLG00019253}. a copy of Technical Guidance Note 18 (Issue 0),^16491649 {CEL00003725}. drafted principally^16501650 Lewis {NHB00003433/9} page 9, paragraph 29(d). by John Lewis of NHBC.^16511651 John Lewis joined NHBC as a building control surveyor in 1997 and from 2013 until he left in October 2021, he was NHBC's specialist fire engineer: Lewis {NHB00003433/3-4} pages 3-4, paragraphs 8-9. The guidance note, entitled Use of combustible cladding materials on residential buildings (which Mr Martin had not previously seen),^16521652 Martin {CLG00019469/44} page 44, paragraph 127. set out three recommended options for securing compliance with paragraph 12.7 of Approved Document B.^16531653 {CEL00003725/2}. Option 1, which has come to be known as the "linear route", referred directly to paragraph 12.7 of Approved Document B and required the use of materials of limited combustibility for all elements of the external wall, including the external facing material.^16541654 {CEL00003725/2}. Option 2 was the classification of a system in accordance with the criteria in BR 135 following a test in accordance with BS 8414. Option 3 was a desktop assessment.

Option 1 and the "linear route"

¶11.55 The interpretation of paragraph 12.7 in Option 1 of the note was not consistent with the meaning Mr Martin and Mr Burd had intended that paragraph to bear when they originally drafted it. They had intended it to cover the core of a composite panel but not the external surface of the cladding material.^16551655 Martin {Day254/37:23}-{Day254/38:6}. In that respect, therefore, the BCA guidance was more restrictive than they had intended.^16561656 Martin {Day254/32:4-8}; {Day254/33:19-25}; {Day254/35:22-24}; {Day254/36:7-11}. Paragraph 12.7 of Approved Document B did not recommend that all components of the external wall of a high-rise building should be materials of limited combustibility.

¶11.56 Mr Martin thought that the BCA guidance note was an effective way of resolving the uncertainty over the meaning of paragraph 12.7 to which he had been alerted by the discussions at the CWCT meeting in July 2014.^16571657 Martin {Day254/42:7}-{Day254/43:15}. He may even have relied on it for that purpose, at least until he could cover it in the next review of the statutory guidance.^16581658 Martin {Day254/43:9-15}; {Day254/44:4-13}; {Day254/55:8-14}. That was not an appropriate position to adopt, however, not least because the department had not publicly endorsed the BCA guidance.

¶11.57 Although the BCA guidance did not have the same status as statutory guidance,^16591659 Martin {Day254/48:9-11}. Mr Martin appears to have thought that it was the most effective way to get the message across.^16601660 Martin {Day254/45:3-5}. He did not think that information published on the department's website was widely read or easily accessible.^16611661 Martin {Day254/49:8-14}; {Day254/88:17}-{Day254/89:9}. There was some evidence that the BCA's guidance note might not have had as wide an audience as Mr Martin assumed,^16621662 Everett {CEV00000001/30} page 30, paragraph 128; Taylor {WIN00000002/61} page 61, paragraph 144. but in any event, he did not think about publishing an FAQ on the matter.^16631663 Martin {Day254/49:8}; {Day254/49:24}-{Day254/50:1}; {Day254/50:25}-{Day254/51:4}. It does not seem to have occurred to him that the BCA's Option 1 might have contributed to further uncertainty about the meaning of paragraph 12.7.

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21 February 2015: The fire at The Torch

¶11.58 On 21 February 2015, the department's Chief Fire and Rescue Adviser, Peter Holland, sent an email to Mr Martin and others in the department about a fire that had occurred in the early hours of that day at The Torch, a high-rise block of flats in Dubai. In it he asked Mr Martin to confirm that such fires should not occur in the UK. Mr Martin did so, commenting that there were provisions in the Building Regulations designed to prevent that kind of problem but noting that there were no guarantees,^16641664 {CLG00031073}. by which he meant that no regulatory system was perfect.^16651665 Martin {Day254/54:19}-{Day254/55:14}. In his response he did not mention the warnings he had received about the way in which the words "filler material" in paragraph 12.7 of Approved Document B was being understood by some in the industry;^16661666 Martin {Day254/60:2-17}; {Day254/60:21}-{Day254/61:5}; {Day254/62:6-15}; Ledsome {Day245/52:7-10}; {Day245/52:19}-{Day245/53:14}. nor did he mention them to Richard Harral or Bob Ledsome, to whom he copied his response. He accepted that he should have done both.^16671667 Martin {Day254/65:13-15}. Mr Martin accepted that he had not been candid with the others to whom the email had been sent about the controversy over the meaning of paragraph 12.7 that he had been aware of since the summer of 2014,^16681668 Martin {Day254/66:4-12}. and agreed that he had known at that stage that there was a risk that the statutory guidance was not being understood correctly.^16691669 Martin {Day254/61:8}-{Day254/62:2}.

June 2015: NHBC's question

¶11.59 Notwithstanding NHBC's involvement in the drafting of BCA Technical Guidance Note 18, on 15 June 2015 Steve Evans wrote to Brian Martin in effect asking him the same questions that Tony Baker of BRE had asked him in November 2013,^16701670 Martin {Day254/132:10-14}. namely, what was meant by the word "filler" in paragraph 12.7 of Approved Document B and to what components of an external wall was it intended to apply.^16711671 {NHB00002792/3}. Like Mr Baker before him, Mr Evans received no proper answer to those questions.^16721672 {NHB00002792/2}. Mr Martin's response was vague; he said that he could not offer a formal view and instead offered an anecdote about the fire at The Edge in January 2005,^16731673 {NHB00002792/2-3}; Martin {Day254/141:1-4}. as he had done in response to Mr Baker. Given that he thought the BCA guidance note covered the very point that NHBC was now raising again, Mr Martin ought to have been seriously concerned. He told us that he had been under the impression that NHBC was involved in a disagreement with a developer^16741674 Martin {Day254/113:13-25}; {Day254/115:16-20}; {Day254/117:15-21}. and that he had therefore told Mr Evans that specific projects were a matter for the relevant building control authority.^16751675 Martin {Day254/130:19-25}; Ledsome {Day245/42:10-15}. That is not apparent from the face of the document, however, in which Mr Evans specifically asked for the department's view on the meaning and scope of the word "filler".^16761676 {NHB00002792/3}.

¶11.60 Mr Martin said that he had to be careful about providing a formal interpretation of the statutory guidance or telling building control what would or would not comply with the Building Regulations. We were not persuaded, however, that he was as constrained as he suggested. Although Mr Ledsome agreed that there was a limit to what officials could say about specific situations,^16771677 Ledsome {Day245/41:22}-{Day245/42:2}; {Day245/42:23}-{Day245/43:2}. he said that there was nothing to stop Mr Martin providing proper answers to questions of a general nature, including the questions that Mr Evans had asked in his email.^16781678 Ledsome {Day245/46:5-18}. Asked why he had not done that, Mr Martin said that at the time he had not thought to do so^16791679 Martin {Day254/133:23}-{Day254/134:8}. and that his response was probably more unhelpful than he had intended.^16801680 Martin {Day254/143:23}-{Day254/144:7}; {Day254/185:2-11}.

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¶11.61 The fact is that, as Mr Martin well knew, he was being asked to respond to a longstanding problem that had created confusion across the industry and needed to be resolved in the next review of Approved Document B.^16811681 Martin {Day254/119:20}-{Day254/120:6}; Martin {Day253/25:17-23}; Martin {Day254/135:16-25}; {Day254/44:4-13}; {Day254/55:19}-{Day254/56:15}; Martin {Day255/84:19-{Day255/85:2}. His failure to tell more senior officials about it at any stage is extremely difficult to understand, particularly since the opportunity to do so arose again and again.

¶11.62 Neither Richard Harral nor Bob Ledsome was aware of Mr Martin's correspondence with NHBC in July 2015 and did not learn of it until much later.^16821682 Ledsome {Day245/40:4-7}; Harral {Day244/118:25}-{Day244/119:2}. Once again, he failed to tell them that there was a difference of view within the industry about the interpretation of paragraph 12.7.^16831683 Ledsome {Day245/53:14}; Harral {Day244/119:3-7}. Moreover, despite the fact that paragraph 12.7 was the only provision in Approved Document B that might have prevented the widespread use in England of aluminium composite panels with unmodified polyethylene cores, Mr Martin did not see a connection between the debate about the meaning of paragraph 12.7 and the assurance he had given Peter Holland in February 2015 following the fire at The Torch.^16841684 Martin {Day254/118:14}-{Day254/119:19}. He should have done so. One obvious reason why there could be no guarantee that a similar fire could not occur in the UK was because the specific provision in the guidance designed to prevent it was being widely misinterpreted, as Mr Martin had known since November 2013.

January 2016: the fire at the Address Downtown

¶11.63 On 31 December 2015 there was another serious fire in Dubai at a 63-storey building called the Address Downtown. On 4 January 2016, Mr Ledsome asked Mr Martin whether as a result there was anything the department needed to worry about in the Building Regulations or Approved Document B. In his response Mr Martin referred to paragraph 12.7 and said that the polyethylene core of an aluminium composite panel would be considered a filler material and so should not be used in the external walls of buildings over 18 metres in height.^16851685 {HOM00043106}.

¶11.64 Mr Martin told us that, as far as he was aware at the time, everyone understood that the core of an aluminium composite panel was a filler material,^16861686 Martin {Day254/167:2-11}; {Day254/170:13-18}. but it is impossible to see how he can have thought that in January 2016, given the debate that had been taking place over the previous eighteen months. It was demonstrably untrue, even on his own evidence. Given his exchange with BRE in November 2013,^16871687 {CLG10005895}. the debate at the CWCT meeting in July 2014^16881688 CWCT Fire Group Minutes of Meeting dated 2 July 2014 {CLG00019336/4} second paragraph. and Mr Evans' clear statement six months earlier that the meaning of "filler" was unclear,^16891689 {NHB00002792/3} final paragraph. Mr Martin must have known that the words "filler material" had not been understood by everyone in the same way. Although he refused to accept the fact, Mr Martin ought to have realised that there was a serious risk that material of that kind was being used on high-rise buildings in this country.^16901690 Martin {Day254/165:8-19}.

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¶11.65 At about the time of the fire at the Address Downtown Dr Crowder had discussed the fires in the UAE with Brian Martin who had expressed the view that, in contrast to this country, there were no regulations in Dubai that would prevent the use of aluminium composite cladding panels with polyethylene cores.^16911691 Crowder {Day229/139:1-16}. That may have been his understanding, but despite knowing that there was confusion over the meaning of paragraph 12.7 of Approved Document B, he had taken no steps in the period between the CWCT meeting in July 2014 and the fire at the Address Downtown in December 2015 to find out whether aluminium composite panels with polyethylene cores were in fact being used in this country.^16921692 Martin {Day254/165:20-24}; Harral {Day244/150:2-5}.

¶11.66 In January 2016 Mr Harral and Mr Ledsome were both unaware that a difference of view existed about the meaning of paragraph 12.7 and again, Mr Martin did not tell them.^16931693 Martin {Day254/173:17}-{Day254/174:10}; Harral {Day244/148:19-24}; Ledsome {Day245/53:5-14}; {Day245/57:8-14}. He could not explain why he had not told them and accepted that he should have done so.^16941694 Martin {Day254/171:6-10}; {Day254/174:4-13}. Mr Ledsome did not think there was a risk that aluminium composite panels with polyethylene cores might be in use on high-rise buildings in the UK.^16951695 Ledsome {Day245/58:6}-{Day245/59:2}. He took what Mr Martin told him on trust^16961696 Ledsome {Day245/56:25}-{Day245/57:7}; {Day245/58:3-5}; {Day245/59:14-17}; {Day245/74:13-20}. accepted that paragraph 12.7 of Approved Document B applied to the cores of such panels.^16971697 Ledsome {Day245/59:18-23}. If there had been any doubt about that, he would have expected Mr Martin to say so.^16981698 Ledsome {Day245/60:5-22}. Mr Ledsome did not check the text of the Approved Document for himself.^16991699 Ledsome {Day245/56:15-24}; {Day245/74:13-20}.

¶11.67 Neither Mr Ledsome nor Mr Harral was told at any time before the Grenfell Tower fire about the results of the test carried out in 2001 on a system incorporating aluminium composite panels under contract cc1924.^17001700 Harral {Day244/67:4-17}; Ledsome {Day242/185:8-20}. Mr Harral knew little about the product^17011701 Harral {Day244/66:19-23}; {Day244/69:4-10}. and thought that the guidance in Approved Document B would preclude its use on high-rise buildings.^17021702 Harral {Day244/68:4-23}; {Day244/125:12-17}; {Day244/139:13-21}. Despite that, he accepted that checks should have been made and that more should have been done, telling us that he wished the division had had the confidence, remit or resources to do that.^17031703 Harral {Day244/144:4}-{Day244/145:21}.

16 February 2016: correspondence with Booth Muirie Ltd

¶11.68 On 16 February 2016, Brian Martin received an email^17041704 {CLG00031093/5}. from Nick Jenkins, then an Executive Director^17051705 Jenkins {BLM00000884/3} page 3, paragraph 1.7. of Booth Muirie Ltd, a company providing architectural cladding services, including the design, fabrication and supply of aluminium composite panels.^17061706 Murden {BLM00000004/1-2} pages 1-2, paragraph 7. In his email Mr Jenkins asked Mr Martin whether he could answer some questions about the meaning of paragraph 12.7 of Approved Document B that he had initially directed to Dr Sarah Colwell at BRE. The key point that Mr Jenkins had made in his email to Dr Colwell was that it was unclear whether paragraph 12.7 was directed to both insulation and the core of an aluminium composite panel and whether the latter should be a material of limited combustibility. He had expressed the view that if it was, only aluminium composite panels classified Euroclass A2 or better could be used on buildings over 18 metres in height in compliance with the guidance.

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¶11.69 In his original email Mr Jenkins went on to say that in his experience Euroclass A2 panels were rarely specified. The vast majority of panels requested were classified Euroclass B or, in many cases, contained an unmodified polyethylene core and were often installed in combination with combustible insulation materials. In a later message pressing Dr Colwell for a response he said that he had discussed the matter with Steve Evans of NHBC and David Metcalfe of the CWCT and referred to the recent fires in the Middle East where fire had been seen to spread over the facades of buildings clad in aluminium composite material.^17071707 {CLG00031093/8-11}. In his email to Mr Martin he said that there was much confusion and misunderstanding in the industry and that the topic was being widely discussed.^17081708 {CLG00031093/5}.

¶11.70 Mr Martin read the emails, including the original message that Mr Jenkins had sent to Dr Colwell.^17091709 Martin {Day254/194:18-21}. Although he told us that it had been clear to him that Mr Jenkins was correct in his interpretation of paragraph 12.7, he accepted both that that was not clear from the wording and that there was a debate about the matter.^17101710 Martin {Day254/192:19}-{Day254/193:6}; {Day254/194:13-17}. When he responded on 16 February 2016, he told Mr Jenkins that the word "filler" had been added to the text deliberately to cover things that formed part of a cladding system and were not insulation but could provide a means for the spread of fire. He said that it was for the designer and building control body to decide whether the requirements of the Building Regulations had been met and added that his view that the core of an aluminium composite panel could reasonably be considered to be a "filler".^17111711 {CLG00031093/4}. In our view that was an inadequate response to a question that deserved careful attention.

¶11.71 Mr Jenkins tried again later the same day to get a clear response from Mr Martin, telling him that the aluminium composite panels commonly used in the UK would not comply with Approved Document B for use on high-rise buildings and that none of the existing buildings in the UK over 18 metres in height that were clad in aluminium composite panels currently met functional requirement B4. He said that there were many such buildings and that their number was growing. He described the situation as one of grave concern and asked for a meeting to review the guidance.^17121712 {CLG00031093/4}. Mr Martin responded the following day, expressing the view that the text of paragraph 12.7 was "not really all that ambiguous". He invited Mr Jenkins to attend a second meeting of the CWCT's Fire Group in March 2016 and suggested that he contribute his views to the Part B user survey then being conducted by the department.^17131713 {CLG00031093/2-3}. His superficial, hurried and unhelpful response to a serious question that required careful thought was clearly inadequate. A response by Mr Jenkins to the Part B user survey would have achieved nothing since, as Mr Martin accepted, it was not intended to deal with technical aspects of Approved Document B.^17141714 Martin {Day255/25:9-12}.

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¶11.72 Mr Martin did not tell Mr Harral, Mr Ledsome or anyone else in the department about his correspondence with Mr Jenkins or what he had said about the widespread use of combustible aluminium composite panels in the UK.^17151715 Martin {Day255/20:15-22}; Harral {Day244/154:9-21}; {Day244/157:10-15}; {Day244/160:10-19}; {Day244/160:24}-{Day244/161:2}; Ledsome {Day245/65:8-24}; {Day245/67:5-11}; {Day245/72:24}-{Day245/73:9}. They both said that he should have referred the matter to them^17161716 Harral {Day244/160:20-23}; Ledsome {Day245/69:6-16}. and regarded it as a matter of the utmost seriousness that warranted being raised at ministerial level.^17171717 Harral {Day244/158:11-20}. However, their failure to take any action in response to the email sent by Steve Evans on 11 July 2014^17181718 {CLG00000686}. leads us to doubt whether decisive action would have been taken.

¶11.73 Mr Martin told us that in February 2016 he had not previously come across Nick Jenkins or Booth Muirie. He had not known whether what Mr Jenkins was telling him was true and had not recognised the significance of what Mr Jenkins was telling him, given that it was one of many conversations he had about matters of non-compliance.^17191719 Martin {Day255/5:12-23}; {Day255/22:18-21}; {Day255/10:17-25}. However, those were not good reasons for taking no action, since he could easily have contacted Mr Jenkins and asked for more information.

¶11.74 Mr Martin agreed that his reluctance to say what paragraph 12.7 meant made it all the more important to publicise the department's position formally, but said that it had been almost impossible to get anything done in government at the time^17201720 Martin {Day254/199:8-10}. because of the deregulatory policies of the day.^17211721 Martin {Day255/19:17}-{Day255/20:6}; {Day255/20:22}-{Day255/21:2}. A culture of deregulation certainly pervaded the department between late 2013 and February 2016, but it provides no excuse for Mr Martin's failure to take appropriate action in response to the confusion over the meaning of paragraph 12.7.

¶11.75 Mr Martin told us several times that he had underestimated the scale and seriousness of the hazard to which Mr Jenkins had alerted him.^17221722 Martin {Day254/197:4-5}; {Day255/5:16-19}; {Day255/6:19}-{Day255/7:22}; {Day255/8:12-17}; {Day255/14:1-3}. He said that the division dealt with allegations of non-compliance every day^17231723 Martin {Day255/13:15-24}. and that he had not recognised that the danger identified by this particular warning was greater than the other dangers that had been drawn to its attention. However, the information Mr Jenkins had provided was obviously of great potential importance and should not have been ignored.^17241724 Martin {Day255/41:20-23}.

Evidence and statistics

¶11.76 The fact that few, if any, of the fires in Dubai had resulted in fatalities may have played a part in Mr Martin's failure to recognise the danger of the use of aluminium composite materials on high-rise buildings.^17251725 Martin {Day255/7:9-15}; {Day255/31:23}-{Day255/32:2}. He thought it would be difficult to justify changes of a kind that made the guidance more restrictive when the statistics showed a steady reduction in the number of deaths through fire.^17261726 Martin {Day255/38:1-6}. However, relying only on statistics of that kind took no account of the magnitude of the risk that had not yet resulted in fatalities and was fundamentally and dangerously flawed.

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24 February 2016: more industry concerns about ACM PE

¶11.77 On 24 February 2016, Mr Martin received an email^17271727 Soane {CUK00000002/2} page 2. from Alastair Soane, a structural engineer and director of the group of organisations known as Structural Safety,^17281728 Structural-Safety is an organisation that combines the work of SCOSS (UK Standing Committee on Structural Safety) and CROSS (Collaborative Reporting for Safer Structures UK) involving committees of expert volunteers: Soane {CUK00000002/1} page 1, paragraph 1; Soane {CUK00000002/4-5} pages 4-5, paragraphs 6-13. about the fire at the Address Downtown on 31 December 2015. He asked whether similar panels were used in the UK and whether there was a risk of a similar fire occurring in this country.^17291729 Soane {CUK00000002/2} page 2. The honest response would have been that the risk did exist,^17301730 Martin {Day255/44:23}-{Day255/45:3}. but Mr Martin gave the same response as he had given to Nick Jenkins a few weeks earlier, namely, that the core of an aluminium composite panel could reasonably be considered a "filler" within the meaning of paragraph 12.7 of Approved Document B.^17311731 Soane {CUK00000002/3} page 3. He ignored Mr Soane's offer to issue an alert.^17321732 Soane {CUK00000002/2} page 2; Martin {Day255/50:16}-{Day255/51:1}.

¶11.78 That answer plainly misled Mr Soane, who understood it to mean that it was unlikely that such panels were being used in the UK and was therefore reassured by it.^17331733 Soane {CUK00000002/3} page 3; Soane {CUK00000002/17} page 17, paragraph 45. Mr Martin said that he had thought at the time that his response was appropriate^17341734 Martin {Day255/47:3-4}; {Day255/47:23-25}. and that the BCA's technical guidance note had effectively answered the problem.

17 March 2016: the second meeting of the CWCT Fire Group

¶11.79 On 17 March 2016, Brian Martin attended the second meeting of the CWCT's Fire Group.^17351735 Martin {CLG00019469/49} page 49, paragraph 138. Dr Colwell also attended, as did Nick Jenkins, David Metcalfe and Alan Keiller of the CWCT, David White of the NHBC, Stuart Taylor of Wintech, Adrian Pargeter from Kingspan, Clive Everett from St Gobain and others from across the industry.^17361736 CWCT Technical Group Minutes of Fire Meeting dated 17 March 2016 {CLG00019440/1}. The minutes of the meeting recorded the view of those present that paragraph 12.7 of Approved Document B was poorly written and open to different interpretations. The heading was also thought to be misleading.^17371737 CWCT Technical Group Minutes of Fire Meeting dated 17 March 2016 {CLG00019440/2} final two paragraphs. Those present noted that BCA Guidance Note 18 had extended the requirement for insulation and filler material to be of limited combustibility to all materials used in the construction of the external wall.

¶11.80 At the meeting Mr Martin undertook on behalf of the department to revise paragraph 12.7.^17381738 Martin {CLG00019469/49} page 49, paragraph 138. He had agreed with others at the meeting that the paragraph was open to different interpretations^17391739 Martin {Day255/54:2-15}. and accepted that to that extent it had failed in its purpose.^17401740 Martin {Day255/55:18-24}. He could not say when he had come to that conclusion. He told us that the recognition that people did not all understand it in the same way had grown progressively in his mind from about 2014 until the second CWCT meeting.^17411741 Martin {Day255/54:16-25}; {Day255/59:2-7}; {Day255/60:3-6}; {Day255/84:19}-{Day255/85:13}.

¶11.81 The minutes went on to record that the term "filler material" in paragraph 12.7 had been intended to be of wide application, as it was not possible to list all the materials that should be covered by it. Most significantly, they also recorded the conclusion of those present that the paragraph was intended to cover all the materials in the external wall.^17421742 CWCT Technical Group Minutes of Fire Meeting dated 17 March 2016 {CLG00019440/3}. Mr Martin was the only person present who could say what paragraph 12.7 had been intended to achieve,^17431743 Martin {Day255/61:8-14}. but if he agreed (as it appears he did) that the intention had been to cover all the materials in the external wall, that represented a significant departure from his original intention. We think it possible, therefore, that the discussion on this point was more consistent with Mr Metcalfe's recollection, namely, that those present agreed that paragraph 12.7 should apply to all materials in the external wall, not that it did so.^17441744 Metcalfe {CWCT0000115/18} page 18, paragraph 65; Metcalfe {Day228/191:21-24}; {Day228/202:16}-{Day228/203:6}. That would also be consistent with Mr Martin's later approval of the language of Option 1 in BCA Technical Guidance Note 18.

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¶11.82 Mr Martin acknowledged that the interpretation of paragraph 12.7 that by March 2016 he had come to prefer was not one he had ever professed.^17451745 Martin {Day255/65:3-7}. He had come to think that the BCA's interpretation was a safer one that provided a good starting point for designers.^17461746 Martin {Day255/65:12-19}. He had not given any consideration at the time to the effect it would have on paragraph 12.6 and the relevant part of Diagram 40,^17471747 Martin {Day255/67:15}-{Day255/68:1}. but he agreed that it created an anomaly^17481748 Martin {Day255/68:25}-{Day255/69:7}. in that paragraph 12.6 had no part to play if that was the correct interpretation of paragraph 12.7. Mr Martin did not see that as a problem, however.^17491749 Martin {Day255/69:8-23}; Martin {Day254/123:24}-{Day254/124:17}; {Day254/124:25}-{Day254/125:6}; {Day254/126:1-13}; {Day254/128:7-15}. He said that readers of Approved Document B should have recognised that paragraph 12.7 was imprecise^17501750 Martin {Day255/81:20}-{Day255/82:8}. and should have referred back to the functional requirement.^17511751 Martin {Day255/72:2-15}; {Day255/75:8-12}; {Day255/80:2}-{Day255/81:6}.

¶11.83 It seems clear to us that Mr Martin had not given the question enough thought. The purpose of the guidance was to advise readers on how to go about complying with the various functional requirements in commonly encountered situations. If the guidance was so imprecise and contradictory that it had to be disregarded, it simply created confusion. That was a significant and serious problem.

¶11.84 The CWCT meeting on 17 March 2016 was the first occasion on which Mr Martin had stated publicly what paragraph 12.7 of Approved Document B had been intended to mean.^17521752 Martin {Day255/82:13-21}. (Whether it actually bore that meaning, despite the inconsistency it would create with paragraph 12.6, is another matter which we have addressed separately in Chapter 7.) He appears to have thought at the time that the conclusion he had reached would be disseminated by those who attended the meeting and by the guidance that the CWCT planned to publish,^17531753 Martin {Day255/86:15}-{Day255/87:12}. but he did not report the outcome of the meeting to Mr Harral or Mr Ledsome, nor did he tell them that he intended to propose an amendment to paragraph 12.7 when Approved Document B was revised.^17541754 Martin {Day255/87:13}-{Day255/88:5}; {Day255/89:12-20}; {Day255/101:20}-{Day255/102:5}; Harral {Day244/166:9-21}; Ledsome {CLG00019465/54} page 54, paragraph 207; Ledsome {Day245/79:12}-{Day245/80:1}; {Day245/83:9}-{Day245/84:16}; {Day245/88:17-23}; {Day245/96:11-17}. In short, he was complacent and did not appreciate the severity of the risk.^17551755 Martin {Day255/91:24-25}; {Day255/93:4-9}.

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¶11.85 For the same reason, he did not view the problem as urgent.^17561756 Martin {Day255/94:7}-{Day255/95:4}; {Day255/98:22}-{Day255/99:14}. All he could say was that, in his mind, industry guidance was doing the job, but in March 2016 he should have given further thought to the publication of an FAQ.^17571757 Martin {Day255/99:10-14}; {Day255/99:20-22}. He did not make it clear to any senior official that the revision to paragraph 12.7 that he thought was needed could wait until the next review of the document,^17581758 Martin {Day255/100:16-21}. but he knew that the scope of the next revision was still being discussed and that there was no timetable in place for it.^17591759 Martin {Day255/90:1-8}; {Day255/90:20}-{Day255/91:21}; Ledsome {Day245/96:18}-{Day245/97:1}.

28 March 2016: the fire at the Ajman One complex, Dubai

¶11.86 Less than two weeks after the CWCT meeting on 17 March 2016, Mr Martin corresponded with Dr Crowder and Martin Shipp at BRE about yet another high-rise cladding fire that had occurred in the Ajman One complex, Dubai, on 28 March 2016.^17601760 {CLG10008111}. Although he noted that aluminium composite material again seemed to have been involved,^17611761 {CLG10008111/1}. he failed to make the connection between that fire and what Mr Jenkins had told him about the widespread use of similar material in the UK.

7 July 2016: the NHBC's new guidance

¶11.87 On 7 July 2016 Mr Martin spoke at a seminar^17621762 Martin {CLG00019469/51} page 51, paragraph 144. at which the NHBC was launching its new guidance, Acceptability of common wall constructions containing combustible materials in high-rise buildings.^17631763 {NHB00000065}. Mr Martin told us that he had read the guidance when he met Steve Evans and Diane Marshall on 30 June 2016^17641764 Martin {Day255/143:1-6}. and was satisfied that it was a reasonable approach to satisfying the functional requirements of the Building Regulations.^17651765 Martin {CLG00019469/52} page 52, paragraph 146; Martin {Day255/163:19-23}. For the reasons we have given we disagree.

¶11.88 Mr Martin's speech at the seminar was about the regulatory requirements for facades. Nonetheless, for reasons which are not clear to us, he did not use the opportunity to tell those present what he understood to be the effect of paragraph 12.7 following the discussion at the CWCT meeting four months earlier.^17661766 Martin {Day255/128:15}-{Day255/130:3}. He said that he had not been thinking in that way at the time^17671767 Martin {Day255/130:17-22}. and that his mind was on a broad range of issues rather than one particular matter.^17681768 Martin {Day255/130:24-25}; {Day255/131:21}-{Day255/132:23}.

¶11.89 Although no-one at NHBC had told him so, Mr Martin assumed that the guidance note was based on a number of large-scale tests in accordance with BS 8414.^17691769 Martin {Day255/146:18-20}; {Day255/147:13-15}; {Day255/148:3-25}; {Day255/149:23}-{Day255/150:25}; {Day255/151:22}-{Day255/152:4}; {Day255/152:16-18}; {Day255/155:23-25}; {Day255/156:17-23}; {Day255/158:6-13}. He was therefore^17701770 Martin {Day255/146:18-21}; {Day255/152:5-18}; {Day255/158:1-9}. not concerned by that part of the guidance which said that the use of aluminium composite material with a polyethylene core that was not classified Euroclass B fell outside of the scope of the guidance^17711771 {NHB00000065/4} left-hand column under the heading "Restrictions on use". (thereby indicating that if it was classified Euroclass B it fell within it). He agreed that Euroclass B did not indicate a material of limited combustibility^17721772 Martin {Day255/148:2-3}; {Day255/150:12-15}. but said that he had assumed that tests in accordance with BS 8414 had been carried out on systems incorporating panels classified Euroclass B.^17731773 Martin {Day255/149:1-13}.

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¶11.90 Mr Martin accepted that, under NHBC's 2016 guidance, a building control officer could approve a cladding system on a building over 18 metres in height containing a combustible insulation, such as Kingspan K15 or Celotex RS5000, and aluminium composite panels with polyethylene cores classified as Euroclass B.^17741774 {NHB00000065/4}; Martin {Day255/154:2-12}; {Day255/155:14-20}; {Day255/161:15-21}. He appears to have thought that NHBC had assessed the guidance thoroughly,^17751775 Martin {Day255/155:23-25}. including through testing,^17761776 Martin {Day255/148:3-18}; {Day255/151:22}-{Day255/152:4}. but some basic enquiries of Diane Marshall^17771777 Diane Marshall was NHBC's Head of Technical Services between 2012 and 2017: Marshall {NHB00003434/2} paragraph 11(d). or Steve Evans would have revealed that not to have been the case. Although Mr Martin appears to have taken the view that that was not his responsibility,^17781778 Martin {Day255/156:9}. the fact is that NHBC's guidance was inconsistent with what by then he was telling people that paragraph 12.7 was intended to mean. Given Mr Martin's awareness of the risks inherent in using aluminium composite panels with polyethylene cores in the external walls of high-rise buildings, he should not have lent his (and thereby the department's) support to guidance that sanctioned the use of them, even if they were classified Euroclass B. The position was made worse by NHBC's advice that such material could safely be used in combination with Celotex RS5000 or Kingspan K15, PIR and phenolic insulation materials that by common consent were not materials of limited combustibility. Mr Martin should have refused to lend his support to that guidance and should have taken it up with senior management at NHBC.

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