Grenfell Tower Inquiry
The Grenfell Tower Inquiry is a British public inquiry into the Grenfell Tower fire, which killed 72 people and destroyed Grenfell Tower on 14 June 2017. It was ordered by Prime Minister Theresa May on the day following the fire.
May announced on 29 June 2017 that the inquiry would be chaired by retired judge Sir Martin Moore-Bick, with the immediate priority "to establish the facts of what happened at Grenfell Tower in order to take the necessary action to prevent a similar tragedy from happening again." She promised that "No stone will be left unturned by this inquiry." On 15 August 2017, the terms of reference of the Inquiry were announced. The first hearing opened on 14 September 2017.
The Inquiry is divided into two phases: Phase 1 which addressed the events on the night of the fire, and the ongoing Phase 2 which will investigate the wider situation. Hearings for Phase 1 were held in June-December 2018 in Holborn, Central London. The report for the findings of Phase 1 was published on 30 October 2019. The Phase 2 hearings commenced on 28 January 2020 at a location in Paddington. Hearings after 16 March 2020 were suspended until further notice.
Background
Grenfell Tower was a 24-storey residential tower block in North Kensington, London, England. It was completed in 1974, as part of the first phase of the Lancaster West Estate.The concrete structure's top 20 storeys consisted of 120 flats, with a total of 200 bedrooms. Its first four storeys were nonresidential until its most recent refurbishment in 2015–2016, which converted two of them to residential use, bringing it up to 127 flats and 227 bedrooms. It also received new plastic framed windows and new cladding with thermal insulation.
A major fire seriously damaged the building on 14 June 2017, causing the deaths of 72 of the 293 people who were believed to be in the 129-flat tower that night.
Initiation
The day after the fire broke out, Theresa May, the then prime minister, announced that there would be an inquiry into its causes. She made a statement to Parliament on 22 June announced a judge-led inquiry, saying "No stone will be left unturned by this Inquiry".Sophie Khan, who acted as solicitor for some families in the Lakanal House fire, told BBC Two's Newsnight that inquests would be better for the families as they would allow the families to participate and ask questions. She said the coroner was independent but a public inquiry was government-led and she wondered what information the Prime Minister knew that she wanted to hide. Another solicitor, Louise Christian, who also acted for families in relation to Lakanal House, wrote in The Guardian that a public inquiry was the best approach. She wrote about a promised public inquiry for Lakanal House being "downgraded to an inquest" and that inquests would be delayed by a criminal investigation. She acknowledged that victims' interests are often sidelined in a public inquiry but wrote that the scope of a public inquiry is wider and that a rapid inquiry would put the government under more pressure to implement its findings immediately.
Appointment of Martin Moore-Bick
On 29 June, May announced that Sir Martin Moore-Bick, a retired judge, would lead the inquiry. She stated that "Before the Inquiry starts Sir Martin will consult all those with an interest, including survivors and victims’ families, about the terms of reference." Moore-Bick met some survivors of the fire that day, and cautioned against giving the inquiry too much scope.The appointment was met with some criticism from survivors, as well as Emma Dent Coad, the MP for Kensington. The chief criticisms were towards Moore-Bick's background in commercial law, his different social background to the survivors and his previous ruling in a Westminster City Council case, in which he had allowed a local resident to be rehoused 50 miles away. This decision had been overturned on appeal by the Supreme Court. Dent Coad said "We need somebody who can do the detail but we need somebody who can actually understand human beings as well." During two public meetings held by the Inquiry before the finalisation of the terms of reference, various residents criticised the lack of diversity of the Inquiry panel, saying that it did not represent the community.
An anonymous legal columnist in the New Statesman wrote that "The bulk of this objection, it appears, arises out of a rapidly cultivated image of Sir Martin as an establishment Mr Whitewash." The columnist argued that Moore-Bick's background as a "fact finder" in commercial law made him far better suited to the role than a criminal judge, and that getting the inquiry to empathise with the survivors "can be achieved without sacking the chair and starting again." Lord Chancellor David Lidington said Moore-Bick would lead the inquiry "with impartiality and a determination to get to the truth and see justice done".
Terms of reference
The inquiry leadership held a consultation on the inquiry's terms of reference throughout July 2017, which concluded on 4 August.On 30 June, Labour Party leader Jeremy Corbyn wrote to May to say that the inquiry's terms should be broad, because the fire had "much wider implications for national policy issues".
Former Lord Chancellor Lord Falconer said that "The inquiry has got to look at how regime developed, or I think the residents would feel they were let down." On 17 July, he again to May, saying: "As I set out in my letter dated 30 June, there is considerable concern among residents and others that the judge leading the inquiry has already been directed towards a narrowly defined Terms of Reference, which will not bring residents the answers they seek."
On 15 August 2017, Theresa May announced the terms of reference. The inquiry's role would be to examine "the circumstances surrounding the fire", including its causes, how it spread to the whole building, and the adequacy of the regulations and safety measures in place.
Social housing
politicians and some survivors have argued that the inquiry should include an examination of national policy in national policy towards social housing. In his letter to Theresa May proposing the Terms, which were agreed without amendment, Moore-Bick had noted that many of those affected by the fire and others had been in favour of this. He argued, however, that this would add significantly to the time required to complete his work, and that such an examination was better suited to a different kind of process and not to a judge-led inquiry. in her response, Theresa May said that the Housing Minister Alok Sharma would "personally meet and hear from as many social housing tenants as possible" both in the immediate area and further afield.In response, Corbyn wrote an open letter to May saying: "The fire has raised profound concerns about the way that social housing is provided and managed in this country, and I as well as many survivors worry that without a wider focus, the inquiry will fail to get fully to grips with the causes of the fire." Corbyn also said May should "immediately set out a clear, independent and thorough process for identifying and addressing the broader failings that led to the Grenfell fire." Matt Wrack of the Fire Brigades Union said, "Central government has created the housing and fire safety regime and central government must be held to account for any failings in it. Yet the terms of reference signed off by Theresa May appear designed to avoid this."
Controversies
Two former panel members from the Independent Inquiry into Child Sexual Abuse raised concerns about the ability of the inquiry to be independent of the government.Matt Wrack, the general secretary of the Fire Brigades Union, argued that the order of the inquiry made the fire service's role too prominent, while other issues will be addressed in the second phase when public interest will have faded.
On 7 January 2018, an open letter to the Prime Minister signed by 71 academics and several politicians was published. This described concern for a possible conflict of interest of the auditors KPMG, who audited the Royal Borough of Kensington and Chelsea and companies responsible for the cladding on Grenfell Tower. This was viewed by signatories as a conflict with their neutrality on the enquiry. In response, KPMG agreed to immediately withdraw from the enquiry and waive its fees.
Phase One
The inquiry opened on 14 September 2017. Procedural hearings were held in December 2017 and March 2018.In May 2018, a series of commemorative hearings were held in which relatives and survivors paid tribute to the 72 who had died.
Phase 1 evidence
Evidential hearings began on 4 June 2018. The first week saw opening statements on behalf of the key organizations and the presentation of reports by key expert witnesses. No hearings were held in the week beginning on 11 June 2018, as the anniversary of the fire and commemorations fell within this week. The hearings resumed on 18 June 2018.The appointed expert witnesses were:
- Dr Barbara Lane, a fire safety engineer from Arup
- Colin Todd, a fire safety consultant from CS Todd & Associates Ltd
- Professor David Purser, from Hartford Environmental Research
- Professor Edwin Galea, Professor of Mathematical Modelling at the University of Greenwich
- Dr Ivan Stoianov, Senior Lecturer in Water Systems Engineering at Imperial College London
- Dr J. Duncan Glover, from Failure Electrical LLC
- Professor José L. Torero, Director of the Center for Disaster Resilience, University of Maryland, USA
- Professor Luke Bisby, Professor of Fire and Structures at the University of Edinburgh
- Professor Niamh Nic Daeid, from the Centre for Anatomy and Human Identification, University of Dundee
- Rodney Hancox, Director, Gas Distribution Solutions Ltd.
- Steve McGuirk, former Chief Fire Officer of Greater Manchester, Cheshire and South Yorkshire, former President of the Chief Fire Officers Association, and former Lead Adviser to the Local Government Association.
The London Fire Brigade incident logs were also published. Among transcripts that are to be cross-examined in week five, the "operational response" reveals that more than 140 fire engines and 720 firefighters were deployed; deputy assistant commissioner, Andrew Bell, told the inquiry on Thursday that it was probably the largest deployment of breathing apparatuses ever made in the UK.
Firefighters' evidence
Evidence from the firefighters and fire officers was heard from 25 June to 2 October, with a gap in August.The first to testify was Watch Manager Michael Dowden, the initial incident commander. His testimony lasted three days. He admitted that he had been unsure how to respond when the fire began climbing up the side of the building. Some of the questions he answered were repetitous- as they had been independently asked by the victims families. He could not continue when Richard Millett QC, counsel to the inquiry asked about a 12-year old girl.
Moore-Bick praised Dowden for his three days of testimony, saying he had shown "courage and candour". The Fire Brigades Union described the line of questioning about Fire Brigade Policy as "at times absurd" given Dowden's relatively low rank. Matt Wrack, the FBU general secretary said, "There clearly are important and difficult questions to ask but they should not be directed at those who do not have the power or authority to have altered policies, operational procedures or training,"
The first firefighters and officers to testify were among those who were first to respond,
followed by others including senior command staff. Several firefighters reported being in life-threatening situations and felling emotional trauma after being unable to rescue certain residents. Control room staff also testified.
Issues discussed included communications problems, the sheer amount of smoke, the stay put policy that was eventually abandoned, equipment shortages and missing fire safety features in the building such as floor plans.
Dany Cotton, who had been the brigade's Commissioner since January 2017, testified on 27 September. In response to questions about LFB's preparedness, she said the disaster was as unexpected as "a space shuttle landing on The Shard."
She also said that "I wouldn't change anything we did on the night." These remarks draw criticism from survivors groups.
Survivors' evidence
Other Phase 1 evidence
The inquiry also heard from representatives of Kensington and Chelsea Tenant Management Organisation .KCTMO's lawyer said that although the building only had a single stairway "it managed to continue supporting evacuations and firefighting activities throughout the life of the fire" and that expert evidence suggested that 239 people could have got out after seven minutes. She said "The inquiry will want to consider that the stairs at Grenfell Tower could have coped with a full building evacuation." They remained operational throughout the fire; 239 people could have exited within seven minutes if so instructed. Expert Dr Barbara Lane, had said the stay put policy effectively failed at 1.23am, but it was kept in place until 2.37am when 107 people were still inside; 36 lived.
It was revealed that in July 2014 an official from the TMO emailed the project team: “We need good costs for Cllr Feilding-Mellen.” At that point £300,000 was removed from the cladding budget and zinc panels were replaced with the aluminium composite material with a plastic core, which the government has now banned from use on high-rise residential blocks.
The barrister for Arconic claimed that the Reynobond aluminium composite panels cladding had not been responsible for the disaster. If the replacement windows and sub frames had been installed correctly the flames from a simple kitchen fire could not have bridged the gap into the cladding, and could have been put out with a simple fire extinguisher.
Martin Seward counsel for the Fire Brigades Union said that the Royal Borough of Kensington and Chelsea had failed to make an evacuation plan for Grenfell Tower and relied on an outdated "stay put" strategy, leaving it to the fire brigade on the ground to devise an evacuation strategy. He urged the inquiry to give his members from "protection from unwarranted criticism".
October 2019: Phase 1 Report
Sir Martin Moore-Bick issued the first part of the report Wednesday 30 October 2019, though some parts had been leaked days earlier.He found that:
He highlighted Dany Cotton's rhetorical question "It's all very well saying 'get everybody out', but then how do you get them all out?", saying that it demonstrated that the London Fire Brigade had never considered that question before the night of the fire.
Effects
On 6 December, Dany Cotton announced her early retirement effective from 31 December 2019 after 32 years of service. This followed calls from bereaved families and survivors of the disaster for her to quit.Phase Two
Preparation
Campaigners had argued that the inquiry should include an advisory panel to assist Moore-Bick. In May 2018, it was announced that two panelists would sit alongside Moore-Bick for the second stage of the inquiry.There was certain disquiet that phase two would not address the bigger issues of race and class discrimination and the austerity driven housing crisis believed to have underpinned the disaster. Replacing on the panel, an expert on social housing with an engineer, was seen by Grenfell United and the Hillsborough families support group as evidence that their views were about to be sidelined. “They are not listening and they don’t want to listen,” said Nabil Choucair. “The inquiry should be designed to look at the aspects we want them to look at.” Choucair lost 6 relatives in the fire.
Phase 2 is expected to take 18 months. 200,000 unseen documents, from private emails to phone transcripts and commercial agreements, will be released, illustrating decisions taken by the May government, borough councils, and private companies in the months before the fire, and in the immediate aftermath.
A second allegation of conflict of interest surfaced in January 2020. A few weeks earlier, one of the phase 2 panelists had stepped down and Prime Minister Boris Johnson appointed Benita Mehra to fill the post. Mehra was the chair of the Women's Engineering Society charity from 2015 to 2018. The Guardian reported that in 2017 the charity had received a £71,000 grant from the Arconic Foundation, an organisation linked to Arconic, the manufacturer of the panels. Mehra helped draft the application for the grant, which was the largest donation the charity had received that year. Following criticism from opposition politicians and survivors, Mehra expressed regret for her oversight, and resigned on 25 January.
Phase 2 will be divided into eight modules:
- The 2015-16 refurbishment
- The testing, certification and marketing of the cladding panels and external insulation
- The management of Grenfell Tower, including how residents' complaints were handled
- Central and local government responses to the disaster
- The response of London Fire Brigade
- Building regulations and enforcement
- Remaining expert evidence
- Remaining evidence from bereaved, survivors and residents
Module 1
The second phase opened with statements from lawyers for Studio E, the architects of the refurbishment; Rydon and Harley Façades, the buildings; Celotex, who had made the combustible insulation; and Arconic, who had supplied the ACM panels. There were also statements from the Royal Borough of Kensington and Chelsea and the Kensington and Chelsea Tenant Management Organisation.
Lawyers for Rydon introduced emails that showed that Celotex knew that their combustible insulation product was not safe to use with ACM panels as a suitable fire barrier was not available. They produced internal emails from Arconic from 2011 showing that the fire-rating of their Reynobond PE panels had dropped to class E from class B and so were "unsuitable for use on building façades" in Europe.
The combustible cladding panels made by Arconic, which contained the flammable polyethylene core, were chosen as part of an attempt to cut £454,000 from the budget by KCTMO. The architect, builders and fire engineer who worked on the refurbishment knew the cladding system would fail in the event of a fire more than two years before the blaze, in conditions where the fire flamed through windows. The lawyers for Celotex introduced an email thread where Daniel Anketell-Jones of Rydon, discusses the need for a fire stop in the cavity and this was copied and discussed by the other organisations involved.
After the companies' opening statements were read, Richard Millett criticised them for failing to admit any mistakes: "With the sole exception of RBKC, not a single core participant involved in the primary refurbishment of Grenfell Tower has felt able to make any unqualified admission against its own interests." RBKC had admitted its building control body had made errors, while Celotex admitted its marketing of the insulation had been misleading. The Times suggested that the companies' response had been to "blame each other." Millett added: "Any member of the public reading these statements and taking them all at face value would be forced to conclude that everyone involved in the refurbishment of Grenfell Tower did what they were supposed to do and nobody made any serious causative mistakes."
Suspension
On day three and four, witnesses involved in the tower's refurbishment have asked for confirmation that any evidence they give will not be used against them in any criminal proceedings that might take place, before they will give evidence.At the hearing on the 6th February, the chairman ruled that the inquiry should be suspended till at least 24 February to allow the attorney general Geoffrey Cox time. He explained to the victims and families that the right not to self-incriminate was enshrined in English law. This is not the same as being given immunity from prosecution. However the suspension dragged on with the Attorney General wishing to ascertain how many witnesses would demanding immunity, and the chairman pointed out this was of the greatest urgency as a health and safety issue affect hundreds of lives.On the 2 March, a further attempt was made to reopen the enquiry. The attorney general had given the assurance, and Moore-Bick explained that the undertaking meant that “no one will be able to justify refusing to answer questions on the grounds that to do so would or might expose him or herself personally to a risk of prosecution”. Community activists protested loudly that “It’s one rule for them and one rule for the firefighters,” and “It means the firefighters were hung out to dry. It’s a whitewash. It means the inquiry is a whitewash.” Later, Andrzej Kuszell of Sudio E, the architects admitted that refurbishing tower blocks was “something that was not within our normal experience”.
Resumed evidence
This started with evidence, from studio E. At lot of this was about who knew what, and whether they were qualified to do what they did. On Tuesday 3 March 2020 the enquiry heard- The lead architect had no experience of cladding high rise buildings or polyethylene composite materials.
- The Point of contact was not a qualified architect.
- Sounes, the architect said he had “no knowledge” of rapid fire spread and had not read regulatory guidance about how to the design cavity barriers that were intended to stop fire spread and which failed at Grenfell, believing that it was Building Controls job to check his drawings for compliance. He had not heard of Lakanel, or that aluminum cladding could burn.
- An email was produced from Kate Cooney of Exona the fire consultants, four years before the project was signed off, suggesting that they are concerns about the safety of the Means of Escape shaft- but they could massage the scheme to mitigate the dangers, but the existing tower was already not safe. Sounes expected that as building control had signed off the system then it was acceptable. Sounes was taken ill and was not cross examined further.
Week 9 March 2020
On 16 March the panel decided, in the light of the Prime Minister's statement that afternoon, to hold no further hearings for the time being.
Resumption- Monday 6 July 2020
Due to a global pandemic social distancing rules were now in place, and not all of public that wanted to attend were allowed to, but must do with a video link. The bereaved keenly waited attending in person the session that will hear the testimony of the main contractors.The inquiry heard claims that Lawrence, a key executive, failed to respond during the planning process to concerns that the cladding might be dangerous and could lead to a repeat the Lakanal House tower fire in south London in 2009 that killed six people.
Project emails show Rydon, Exova and the architects Studio E discussed the fire safety of the cladding before its installation, including warnings it might fail. Tony Pearson, of Exova, told the architects: “If significant flames are ejected from the windows, this would lead to failure of the cladding system, with the external surface falling away and exposing the cavity.”
In November 2014, an official at the Kensington and Chelsea Tenants Management Organisation asked Lawrence to clarify the “fire retardance of the new cladding” Lawrence did not reply, the inquiry has heard.
The inquiry has also heard that Studio E manipulated its fees to avoid the contract being put out to open tender.
Wednesday 6 July
The enquiry hears the fire engineer, Ashton, on the refurbishment at Exova say his responsiblilites were limited to the reconstruction of the tower, not plans to reclad it. He had received a large envelope from studio-E that contained the drawings and plans for the recladding, but hadn't opened it. A package with information on new rain screen cladding, curtain walling and replacement windows was sent and he had been asked to “look it over” but hadn't. He also had not throroughly read the building guidelines "BR 135 guidance on fire spread in external walls". He had never visited the site: in spite of this he penned the Fire Strategy document that the Design team at Studio E referred to.Monday 13 July
Building Consent was explored. RBKC had a reputation for sticking to the letter of the regulations. Obtaining building consent is seen as being a process of negotiation. One proposal is put forward and a compromise reached. RBKC were adamant that the new wall structure must include fire stopping barriers with a two hour rating. Studio E architects found this unnecessary claiming the job was done by the cavity barriers.Monday 20 July
Chris Holt, Rydons site manager attested: “I was aware that as the refurbishment was to a residential block of flats, one of the main risk factors would be fire safety. When I started on the project I spoke to Simon Lawrence and asked whether I was required to consider aspects of fire safety in my role. Simon informed me that it was not part of my role and had been dealt with.”Rydon did not normally employ specialist fire consultants and felt “comfortable with the risk”, as it had done before on social housing blocks: they believed they were using competent specialist sub-contractor. Rydon had assured RBKC and the architect that they were employing a fire expert in meetings in April, June, July, September and October 2014. Thus the cladding material had been chosen without consulting a professional. Lawrence confirmed this.
Simon Lawrence, an executive of Rydon, the principal contractor was testifying. He explained he knew that RBKC was attempting to save £800,000 on the job and to win the contract offered to save £293,368 by switching from the originally specified zinc cladding to the plastic-filled aluminium panels. The bid was accepted. Lawrence was not aware of the increased danger and hadn't researched it. However, the saving was £419,627, but this was never mentioned to the client. Rydon itself had undercosted the job and was trying to make up a £212,000 shortfall.