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Grenfell Tower Inquest | Learnings from the Phase 2 report
Written by Natasha Hamblin CMIOSH, TIFSM on 10 September 2024
On Wednesday, 4 September, the Grenfell Tower Inquiry Panel published its second and final report in response to the Grenfell Tower fire, which resulted in the deaths of 72 people in 2017.
The report laid bare years of missed opportunities to prevent the catastrophe and highlighted how those responsible for fire safety were at risk of being compromised by commercial interests.
In this blog, we take a look at some of those failings and their implications for employers.
Key takeaways from the report
Phase 2 of the report revealed:
- Systematic dishonesty about panels and insulation. Testing processes and misrepresented test data to mislead the market was engaged by producers and suppliers of panel and insulations products.
- Regulation at the time was seriously defective. The system of regulating the construction and refurbishment of high-rise residential buildings in place at that time was defective in a number of respects.
- Conflicts of interest in the system. The report revealed an inappropriate relationship between approved inspectors and those they were inspecting. Approved inspectors had a commercial interest in acquiring and retaining customers, which conflicted with their performance of their role as guardians of the public interest and, as a result, the inspectors sacrificed rigorous application of principle to its commercial interests.
- The government knew of the risks for years. 26 years prior to Grenfell in 1991, an 11-storey tower block in Merseyside suffered a serious fire which involved combustible cladding panels and insulation. The department was aware of the risks but failed to act. In 1999, the Environment and Transport Select Committee warned the government that it should not take a deadly fire for steps to be taken to minimise the risks posed by some external cladding systems.
- Uncaring attitudes and bullying. Relations between the Tenant Management Organisation (TMO) responsible for running services at Grenfell Tower and its residents were found to be increasingly characterised by distrust, dislike, personal antagonism, and anger. Some occupants regarded the TMO as an uncaring and bullying overlord that belittled and marginalised them. The report found that there was a toxic atmosphere fuelled by mistrust of both sides, but there was a serious failure by the TMO in allowing the relationship to deteriorate to such an extent. The TMO and the Royal Borough of Kensington and Chelsea were jointly responsible for managing fire safety at Grenfell Tower but the years between 2009 and 2017 were marked by a persistent indifference to fire safety.
- The need for better regulation. One of the foremost recommendations in the report was to establish a single independent body to regulate the industry and drive change, with this body reporting to a single government secretary of state. Its functions would include regulating construction products, testing and certification, licensing of contractors to work on higher-risk buildings, carry out research, and accrediting fire risk assessors. It suggested that the secretary of state this body would report to should have a chief construction adviser. The report also called for the profession of ‘fire engineer’, which currently requires no formal qualification to practice, to be formally recognised, and for the title and function protected by statute.
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What this means for employers
With the phase 2 report shining further light on the importance of robust fire safety measures, it is imperative that organisations.
Ensure contractors have been vetted for compliance
The report named project managers and site managers involved in the refurbishment works leading up to the disaster. It is clear from the investigation that a number of individuals responsible for ensuring works were carried out to legislation did not have the skills, knowledge, training or experience to do so. It is therefore important to have proof that your subcontract supply chain is robust.
Understand their individual responsibilities under CDM
Organisations must ensure they are fully accountable under the Construction (Design and Management) Regulations 2015 (CDM) when carrying out any refurbishment works or building projects. This includes establishing whether you are a client, principal designer, principal contractor or subcontractor under CDM Regulations and reviewing your legal duties. Evidence of compliance with your legal duties should be retained within company records.
Establish whether a Fire Safety Strategy is in place for the buildings or premises you are involved in refurbishing or constructing and ensure you understand:
- Means of warning
- Means of escape
- Internal fire spread / passive fire protection
- External fire spread
- Access/facilities for the fire rescue service
- Other factors – sprinklers, smoke control/ventilation systems, etc.
- Fire safety management for the building
If there are any changes to these factors during your works, these must be relayed to the principal contractor / client so that a fire engineer/fire risk assessor can review it before works start.
Complete/provide information for the health and safety file
This section of the report has its own chapter (Chapter 61 of Volume 4, part 6), underscoring its importance.
The inquest found that no health and safety file for Grenfell Tower was in place when the refurbishment work began, despite numerous works on the tower over the years. Up until 2007, the duty to produce the health and safety file lay with the CDM co-ordinator; however, when CDM changed in 2015, that duty transferred to the TMO as principal designer.
The report found that during refurbishment works between 2012 and 2016, contractors’ information had not been collated by the principal designer as this was deemed normal to provide information after works have been completed. A thorough analysis of the contents of the health and safety file presented to the TMO identified information was missing, inaccurate or incomplete.
Following refurbishment works, the health and safety file available was not presented in a form that made it readily usable. The TMO failed to ensure that the file was properly organised and contained up-to-date information about the refurbishment. Overall, it was incomplete, confusing and thoroughly unhelpful.
With this in mind, it is important for organisations to ensure they have provided the principal designer with all up-to-date drawings throughout the build and final confirmation at the end of works. Additionally, make sure that operation and maintenance manuals/information are submitted to the primary designer within a timely manner post-works. The timeframe should be agreed by management and monitored.
Need specialist fire safety support?
For advice and assurance around your organisation’s fire safety measures, including support with fire risk assessments, contact WorkNest’s Health & Safety specialists on 0345 226 8393 or request your free consultation using the button below.