Grenfell Tower Inquiry: Phase 2 Report

Background

What it found

1. The Panel concludes that the fire was the culmination of decades of failure by central government and others in the construction industry to look into the danger of combustible materials in the external walls of high-rise homes and to act on what they knew. p. 9 p. 213

   “We conclude that the fire at Grenfell Tower was the culmination of decades of failure by central government and other bodies in positions of responsibility in the construction industry to look carefully into the danger of incorporating combustible materials into the external walls of high-rise residential buildings and to act on the information available to them.”

2. The report finds that the government department responsible for building regulations was warned about combustible cladding and insulation from 1999 onwards and did not amend or clarify its guidance, never published the results of a 2001 test in which aluminium composite panels with polyethylene cores burned violently, and, after the Lakanal House fire in south London in 2009, in which six people died, let a deregulatory agenda delay matters affecting the safety of life. p. 9 p. 10 p. 10 p. 11 p. 213

3. The report finds that the Building Research Establishment, which tested external wall systems, failed to tell the government clearly what its tests showed, and that weaknesses in its testing left it open to manipulation by manufacturers. p. 11 p. 11 p. 11

4. The Panel finds systematic dishonesty by the companies that made and sold the cladding panels and insulation used on the tower, Arconic, Celotex and Kingspan, and that the bodies that certified their products failed to check what they were told. The detail is in Part 3. p. 12 p. 12 p. 13 p. 14 p. 12 p. 15

   “One very significant reason why Grenfell Tower came to be clad in combustible materials was systematic dishonesty on the part of those who made and sold the rainscreen cladding panels and insulation products. They engaged in deliberate and sustained strategies to manipulate the testing processes, misrepresent test data and mislead the market.”

5. The report finds that the choice of combustible materials for the refurbishment resulted from a series of errors by the organisations and individuals involved, each of whom assumed that someone else was responsible for fire safety; and that RBKC and the TMO showed a persistent indifference to fire safety in the years before the fire. The detail is in Parts 4 to 6. p. 20 p. 321 p. 18

   “The choice of combustible materials for the cladding of Grenfell Tower resulted from a series of errors caused by the incompetence of the organisations and individuals involved in the refurbishment.”

6. The report finds that the London Fire Brigade (LFB) had been forewarned by the Lakanal House fire of the shortcomings that appeared again on the night of the Grenfell Tower fire and had not put them right, and attributes that to its leadership and a culture of complacency; it echoes the Phase 1 finding that the firefighters on the night showed great courage. p. 207 p. 210 p. 207

   “The evidence clearly shows that the LFB's failure was attributable to a chronic lack of effective leadership, combined with an undue emphasis on process and a culture of complacency.”

7. The report finds that in the first week after the fire the response of the government and RBKC was slow and piecemeal, that many of those who had lost their homes or family members were left feeling abandoned, and that the local community and voluntary organisations provided support when the authorities did not. p. 28 p. 171 p. 29

8. Asked by some of those representing the bereaved, survivors and residents to examine whether race or social background played a part, the Panel reports some evidence of racial discrimination in how survivors were treated in the days after the fire, and no evidence that racial or social prejudice affected the decisions that created a dangerous building. p. 7 p. 7

Where to start reading

Short on time? These sections carry the report's argument. Each opens at the start of the section.

1. Chapter 2: Executive summary p. 9 · Read →

   The Panel's own summary of all fourteen Parts of the report, from the regulatory regime to the response after the fire; the place to start (Volume 1).

   “The purpose of this chapter is to describe in broad terms the contents of the report and the main conclusions we have reached about the events that culminated in the tragedy at Grenfell Tower.”

2. Chapter 67: Conclusions p. 319 · Read →

   The Panel's conclusions on the refurbishment of 2012 to 2016 and the firms that designed and carried it out (Volume 4).

   “Regrettably, the Grenfell Tower refurbishment was marked by a serious lack of competence on the part of many of those engaged on it and, in the case of some manufacturers of construction products, outright dishonesty.”

3. Chapter 83: Conclusions p. 207 · Read →

   The Panel's conclusions on the London Fire Brigade, its leadership, and what it did with the lessons of the Lakanal House fire (Volume 5).

4. Part 9: The deceased p. 5 · Read →

   The Panel's findings, floor by floor, on the circumstances in which each person who died lost their life, made to assist the coroner; its introduction explains what is recorded and why (Volume 6).

   “It is of the utmost importance that our description of the circumstances in which people died are placed in the larger context of their lives and the pictures of them painted at the memorial hearings. Only in that way can they be remembered as the people they really were.”

5. Chapter 107: Conclusions p. 171 · Read →

   The Panel's conclusions on how RBKC, the TMO, London and the government responded in the days after the fire, and on the local community that filled the gap (Volume 7).

   “No response to an emergency can be considered effective if it leaves those whom it is supposed to serve feeling abandoned and bereft.”

6. Part 14: Recommendations p. 229 · Read →

   The Panel's 58 recommendations, from a single construction regulator and a review of the statutory guidance to fire safety strategies, the fire service and the response to emergencies (Volume 7).

   “As appears from the findings in our report, we are satisfied that the system of regulating the construction and refurbishment of high-rise residential buildings that existed at the time of the Grenfell Tower fire was seriously defective in a number of respects.”