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Grenfell inquiry: Tower refurbishment failed to comply with building regulations

Grenfell one month on

The Studio E Architects-designed refurbishment of Grenfell Tower failed to meet building regulations, the judge leading the inquiry’s long-awaited report into the fire has said

The probe’s first phase report into the blaze that killed 72 people in June 2017, published this morning (30 October), is heavily critical of the fire brigade’s ‘gravely inadequate’ response to the fire.

Inquiry chairman Martin Moore-Bick’s 1,000-page report, informed by 50,000 pages of evidence, found that fewer people would have died had the fire brigade taken certain actions earlier.

But it also pointed to failures in the 2016 upgrade, in particular the cladding, which it found was the ‘principal reason’ for the fire’s rapid spread.

The aluminium composite material (ACM) cladding acted as a ‘source of fuel’ while the fire’s progress was also accelerated by combustible materials in the insulation and the window surrounds, Moore-Bick said.

The ‘decorative’ architectural crown of the tower was also played a ‘significant role in enabling the fire to spread around the building’, the report found.

The document also states that there was ’compelling evidence’ that Grenfell Tower’s external walls – reclad during the Studio E-designed refurbishment – did not comply with the building regulations requirement to ‘adequately resist the spread of fire’.

‘On the contrary, they actively promoted it’, the report notes. 

There is compelling evidence that Requirement B4(1) was not met in this case

He said: ’There is compelling evidence that Requirement B4(1) was not met in this case. It would be an affront to common sense to hold otherwise.’

Moore Bick said that phase 2 of the inquiry would examine why those responsible for the design of the refurbishment considered the tower would meet that ‘essential requirement’. 

As for the cause of the fire, the inquiry concludes that an ‘electrical fault in a large fridge-freezer’ in Flat 16 started the fire, the precise nature of which investigators were unable to establish. 

However, Moore-Bick said the exact cause was ‘of less importance than establishing how the failure of a common domestic appliance could have such disastrous consequences’.

The report also found there were ’systemic failures’ in the fire brigade’s response to the fire, including no ‘contingency plan’ for the evacuation of the tower and it also found they failed to revoke the ‘stay-put’ policy advice when the stairs remained passable.

‘Had it done so, more lives could have been saved,’ it said.

The first phase was supposed to focus solely on the events the nights of the fire, while the refurbishment of the building will be examined in phase 2.

However, the report’s attack on the fire brigade has led critics to argue that the inquiry is ‘back to front’ and that the rescue service was being treated as a scapegoat for the failures of the building. 

Following the leak of the report yesterday, general secretary of the Fire Brigades Union, Matt Wrack, told the BBC: ’The truth is that the fire spread the way it did because it was wrapped in flammable cladding. The firefighters turned up after that had happened, after the building had already been turned, in reality, into a death trap.

‘Firefighters’ actions on the night, which were remarkable in the circumstances, are now being scrutinised. Nobody is trying to avoid scrutiny, but we think that the ordering of the inquiry is completely back to front.’

While the refurbishment of the building will be further examined in phase 2, Moore Bick made a series of recommendations (see below) on how fire safety of high-rises can be improved.

He has however stopped short of calling for the retrofitting of sprinklers in all tall buildings explaining he had not yet studied the evidence on this point.

In a letter to the prime minister, Moore-Bick said: ‘The report contains a number of recommendations which I am confident will improve the safety from fire of those who live in high-rise buildings.

‘They require urgent action to be taken by the government and others who have responsibility for the oversight and direction of the emergency services, in particular the London Fire Brigade. I look forward to their implementation without delay.’

He also called on the government to progress with remedial work to strip ACM cladding from buildings as ‘vigorously as possible’ and said ‘particular attention’ should be paid to decorative features composed of combustible materials.

While stopping short of recommending the measure, Moore Bick also said the government should consider whether England should follow Scotland’s example and lower the threshold for what is considered a high-rise building from 18 metres to 11.

Phase 1 recommendations on fire safety 

Evacuation plans

Building owners should be required by law to develop evacuation plans for all high-rise buildings

Fire service knowledge of materials

Owners and managers of residential towers should be ordered by law to inform the local fire service about the design and construction of its external walls and materials. All fire services should ensure that personnel at all levels understand the risk of fire taking hold in the external walls of high-rises


High-rise residential building owners and managers should be required by law to provide their local fire service with up to date plans, in both paper and electronic form, of every floor of the building identifying the location of key fire safety systems. Buildings should have their own information box with up to date floor plans and information about the nature of any lift intended for use by fire service.


Floor numbers should be clearly marked on each landing within the stairways and in a prominent place in all lobbies.


High-rise building owners and manager should be required by law to carry out regular inspections of any lifts designed to be used by firefighters in an emergency and carry out regular tests of mechanisms which allow firefighters to take control of the lifts.

Fire doors

Owners and managers of residential building which contain separate homes should carry out urgent inspection of all fire doors and that they be required by law to carry out checks at least every three months to ensure they are in working order.



Readers' comments (4)

  • The decision of the LFB to not to evacuate played a large part in this tragedy. After the Lakmal in 2009 it was recommended that this policy was revised. It never was. The Minister responsible was the ineffective Eric Pickles. Ministers are very good at promises, not so good at carrying them out? And very good at doing nothing!

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  • Am I missing something here? I understand that the refurbishment was a PFI contractor led one, and that the architects' original specification was cost cut to save a few million off the tender price?

    This disaster has brewed for a long time, and it will happen again, soon. Forty years of neoliberalism, privatisation and deregulation takes its toll. Bring back traditional, architect-led procurement and the clerk of works. That is the only way the 'golden thread' that has been ripped out of the construction industry will return.

    It is shameful that this inquiry is taking so long, has started the wrong way around and the fire brigade are being blame for a fire that should never have happen, which is more or less impossible to fight. People are not fooled by this attempt to obfuscate matters and try and sweep the systemic failures of decades under the carpet. Justice will be done in the end, even if it takes decades. Never give up the fight!

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  • 'They (i.e. the report's recommendations) require urgent action to be taken by the government and others who have responsibility for the oversight and direction of the emergency services, in particular the London Fire Brigade. I look forward to their implementation without delay.'
    Here's hoping - but the government minister responsible for acting on the reported causes of the previous Lakanal House fire tragedy has been criticised for apparently failing to do so - and in fact he was elevated to the peerage.
    The inaction after that horror is clearly very relevant to the even bigger horror of the Grenfell Tower fire.
    But the government's possibly most relevant action was - according to the National Audit Office - to cut central funding to fire and rescue services by 30% between 2010 and 2015, with further cuts of 20% to 2020 having been set out in the Local Government Settlement.
    What price the cost of people's lives?

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  • Blaming the London Fire Brigade for the deaths of the remaining 71 occupants, plus a previous evacuee who subsequently died, is wrong on three accounts.

    First, although the cladding had rendered it redundant from the moment it was applied to the building, the ‘stay put’ policy was still in place when the fire broke out, and for good reason. Fire and Rescue Services in England attended 169,588 fires in the year ending December 2017. Including those from the Grenfell Tower fire, there were 321 fire-related fatalities in that time, which is one death for every 528 fires. Fires break out every day in London’s tower blocks, and nearly all of them are contained by the compartmentation designed into the fire-safety system of the building until the fire brigade arrives and puts them out. The ‘stay put’ policy is based on these facts, not on retrospective intuition of what should have been done.

    Second, all the residents that lived on the 10th floor of Grenfell Tower and below escaped the fire. Those above had greater difficulty escaping not — presumably — because they all started trying to leave the tower at a later time than those below, but because of the greater difficulty they had in descending through the smoke and heat for the longer time it took to reach safety. As a result, 17 people died on the 11th to 16th floors; and 53 people died on the 17th floor and above, of which 15 moved upward, away from the smoke and flames, to the 23rd floor, where a total of 28 people died. A further 2 people died in hospital after having evacuated Grenfell Tower.

    It is hard to avoid the conclusion that if the fire-safety advice was to leave the building immediately far fewer residents would have died. But there are good reasons why it is standard procedure. When a fire breaks out in a residential block, the stairwell is not there for residents to escape by but for firefighters to get access to the dry risers on each landing, attach the fire hoses and put the fire out as quickly as possible from within the building. The presence of residents on stairwells is, as best, likely to inhibit the ability of firefighters to get to the fire. Moreover, the opening of numerous fire doors at the same time by evacuating residents can create a chimney effect that will spread the fire quicker. At worst, the mass evacuation of residents will lead to a crush liable to endanger residents’ safety. We shouldn’t forget that the largest loss of civilian life in a single incident in Britain during World War II was a result not of a bomb but of a crush on the stairway to the Bethnal Green tube station in March 1943, when 173 lives were lost.

    The public inquiry will hopefully establish why the emergency lights in the stairwell didn’t turn on; why the newly-installed smoke detectors and extractors in the lobbies didn’t function, reducing visibility for both residents and firefighters to zero and eventually making them impassable; why the newly-installed lifts failed to operate, inhibiting firefighters’ ability to establish a bridgehead in the lobbies and reducing the time firefighters could conduct their search and rescue attempts; why fire sprinklers had not been retro-fitted to the 23-storey tower against the advice of the Lakanal House fire coroner and the All-Party Parliamentary Fire Safety and Rescue Group; and why the firefighters, as residents had warned, had difficulty gaining access to the newly developed land around Grenfell Tower.

    Given the total undermining of the fire-safety system of Grenfell Tower by the application of the cladding system, on top of the litany of failures already existing within that system, the Grenfell Tower fire presented the London Fire Brigade with a situation unprecedented in the UK, and whose threat to residents even the deaths of 6 residents in the Lakanal House fire had only intimated. Dr. Barbara Lane, a Chartered Fire Engineer who was commissioned by the Grenfell inquiry to produce a report on the fire, is as unequivocal about where the blame for this lies as the Inquiry is in pointing its finger at the London Fire Brigade: ‘In my opinion, it is not acceptable to expect the fire brigade to mitigate for combustible external wall construction in high rise residential buildings.’

    And third, blaming the failures of the London Fire Brigade to react to the unprecedented ferocity of the Grenfell Tower fire against the procedures which – if the fire-safety system had not been so completely compromised – would have been correct, unfairly portions the responsibility for the deaths. 223 residents escaped the fire, of which 65 were rescued by firefighters who entered the building above the fire, against procedure and often without breathing apparatus, putting their own lives at risk. Those residents who stayed put and died did so not only because of initial advice from the London Fire Brigade that was following standard evacuation procedure, but because the fire-safety procedures the Kensington and Chelsea Tenant Management Organisation installed on every landing of the tower just three months before the fire clearly instructed them to do so. In summarising her findings Dr. Lane writes: ‘It is important to note here that this evidence was not available to decision makers or residents on the night.’ It was, however, available to others.

    From blaming the deaths from the Grenfell Tower fire on the London Fire Brigade it’s only a small step to blaming the residents for not leaving the burning building quickly enough, as if the fire safety procedures of a tower block being made redundant in half an hour is something both residents and firefighters should be expected to face and respond to with all the benefit of hindsight. As ASH laid out in our report on the fire two years ago, and which nothing emerging from the Inquiry has contradicted, responsibility for the deaths of 72 people in the Grenfell Tower fire lies in varying degrees with the private contractors and consultants responsible for the design, manufacture, application and approval of the flammable and badly-fitted cladding system; with the Tenant Management Organisation responsible for the fire-safety of the block, for overseeing its refurbishment, and for retaining the ‘stay put’ policy which that refurbishment had rendered redundant; with the Kensington and Chelsea council responsible for setting the budget that determined the selection of the cheaper materials employed in the refurbishment, that repeatedly ignored the residents’ fears and warnings about the fire safety of the building, and that had received 43 Enforcement Notices on its other properties from the London Fire Brigade in the three years prior to the Grenfell Tower fire; with the civil servants and politicians responsible for sitting on recommendations to review fire safety following the Lakanal House fire against the expert advice of the coroner’s investigation, the London Fire Brigade and the All-Party Parliamentary Fire Safety and Rescue Group; with the Government ministers responsible for initiating the estate regeneration programme that is subjecting the housing stock of London councils such as Grenfell Tower to the demands of market forces intent on realising the potential value uplift in the land they stand on at the expense of the homes and safety of residents; and, finally, with the successive governments, Conservative, Coalition and Labour, responsible for privatising the process through which compliance with building regulations is approved, which has resulted in the safety of residents effectively being put out to competitive tender between private consultants, as it was for Grenfell Tower.

    Ignoring this long chain of responsibility that leads directly back to the government to instead blame the women and men of the London Fire Brigade who put their lives at risk to rescue as many residents as possible from the inferno is not only a disgraceful sleight on their bravery and efforts, but stinks of another government cover-up in the legacy of Orgreave and Hillsborough.

    Simon Elmer
    Architects for Social Housing

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