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With fraudulent exterior material manufacturers The 2017 Grenfell Tower fire has been blamed on government agencies focusing on cutting costs rather than upholding safety standards.
As well as the London Fire Brigade, incompetent and weak regulators, and careless architects and other contractors were also criticised.
The fire resulted in the “avoidable” deaths of 72 residents, aged between six months and 84 years old.
The investigation took six years, held more than 300 hearings and considered some 1,600 testimonies.
Government failure
The report said former prime minister David Cameron’s Conservative government and others had achieved the “culmination of decades of failure” by focusing primarily on deregulation and cost-cutting.
The report states: “The government’s deregulation plans, enthusiastically supported by some junior ministers and secretaries of state, dominated departmental thinking and even issues affecting the safety of lives were ignored, delayed or ignored.”
This is not to say that the previous Labour government is blameless: it was also in power when serious fire safety warnings were issued.
The then Labour government had the opportunity to respond to the “shocking results” of large-scale tests on combustible cladding back in 2001 but failed to communicate the dangers to industry.
Meanwhile, the response to a fire at Lakanal House, a high-rise building in south London, in 2009 was delayed or ignored, but guidelines on external wall construction were not changed.
Kensington and Chelsea
The Royal Borough of Kensington and Chelsea was accused of failing to scrutinise the design and choice of materials, or ensure the work complied with building regulations.
The report states: [the local authority] Therefore, they bear a great deal of responsibility for unsafe conditions in the building immediately after the work is completed.”
The regional and central government responses were criticised as “confused, slow, indecisive and piecemeal”, leaving many victims feeling abandoned by the authorities and forced to rely instead on the help of volunteers.
Rogue Manufacturer
The report said exterior cladding manufacturers had engaged in “systematic fraud” by manipulating safety tests and misrepresenting their results.
The paper harshly criticized Arconic, the American aluminum manufacturer formerly known as Alcoa, saying the company “deliberately concealed from the market the true dangers” of using aluminum in high-rise buildings. Arconic denies that it concealed information or misled certifying agencies, customers or the public.
Another company that made foam insulation, Celotex, “embarked on a fraudulent scheme to defraud customers and the market at large,” the report said, while Kingspan was criticized for selling insulation that was not suitable for use on the exterior of high-rise buildings.
The exterior is clad in aluminum and polyethylene sheathing, with two sheets of aluminum over a layer of foam insulation, surrounded by a layer of polyethylene, a flammable plastic polymer that melts and drips when exposed to heat.
Decentralized Regulation
The report criticised the various regulators involved in the construction industry and said they should be replaced by a single independent regulator.
The National Housebuilding Council has come under fire for failing to ensure its building control function is “free from commercial pressures”.
The new regulator could oversee construction products and building controls, conduct research and share best practices, according to the study.
The report states: “The establishment of such a regulator would have many benefits, including providing a focal point to drive much-needed change in the culture of the construction industry.”
“Sharing best practices across the industry must be a top priority for the new regulator.”
“This will allow for effective sharing of information and promote the exchange of ideas between those responsible for different aspects of the industry. It will make it easier to share information on industry trends both domestically and internationally.”
Building Inspector
Currently, building inspectors are employed by local governments or recruited through a competitive process from the private sector.
The inquiry recommended that an independent committee be set up to consider whether this was in the public interest.
One alternative would be to create a national authority for building regulations, taking over responsibility from city halls.
Architects and Builders
The report criticized the architectural firm, Studio E, which designed the exterior wall and selected the materials.
The company recommended the use of weatherproof panels, but ultimately the unsafe cladding was chosen primarily for cost reasons.
Building contractor Lydon also offered cost savings through its relationship with exterior subcontractor Harley Facades.
The report said Lydon was “substantially responsible for the fire” and that Hurley was “substantially responsible for the fire because he assumed others would ensure safety”.
Fire brigade
The London Fire Brigade was also criticised for being ill-prepared to deal with fast-spreading blazes in high-rise residential buildings – an investigation found it had not responded properly to failings in the 2009 Lakanal House fire, which killed six people.
The report said: “The tragic conclusion is that the Lakanal House fire in July 2009 gave the LFB advance warning of the existence of defects, which became apparent again on the evening of 14 June 2017.”
“These shortcomings could have been avoided if the London Fire Brigade had been directed more effectively in many respects, particularly in its response to the Lakanal House fire, and if it had used its knowledge of the risks arising from modern materials and construction methods.
“However you look at it, this is a serious indictment on an institution whose primary purpose is to protect the public, and the quality of its leadership.”
Given the fire service’s failings, the inquiry recommended establishing a Fire and Rescue College to improve training for firefighters and change the way materials are tested for fire safety.
Potential prosecution
Police said they would review the findings of the investigation before deciding on charges, which could include corporate or personal manslaughter, fraud and health and safety breaches. Charges are unlikely to be filed before late 2026.
Deputy Commissioner of the Metropolitan police, Stuart Cundy, said: “We must review this report alongside the evidence from the criminal investigation to bring justice to those who died and all those affected by the fire.”
“As I said, this will take at least 12 to 18 months.
“This will ensure the strongest possible evidence is presented to the Crown Prosecution Service so that they can make a charging decision.”
“I can’t imagine what an extended police investigation like this will mean for the families and survivors, but we only have one chance to get it right.”
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