What Really Caused The Grenfell Tower Fire | Decades of Negligence and Systemic Failures

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Today's occurrence happened in London, England. When the Grenfell Tower fire

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happened, the suspected scale of negligence that was initially revealed was enormous.

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So much so that they came out and said they would need several years to go through

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everything and decided to release their findings in two phases because of the

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sheer scale of information.

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The first phase was focused on the events on the night of June 14, 2017.

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The fire that claimed 72 lives and to identify,

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as best they could, what happened when the fire started in Flat 16 at 1254 a.m.,

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all the way to when the last survivor managed to escape at 807 that morning.

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The reason behind doing that was to give residents and firefighters the chance

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to tell what happened that night as soon as possible, and to establish what

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happened that morning before determining what went wrong and why. Why?

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Phase two was created to answer the question, how could a modern fire-resistant

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building in London become a deadly trap?

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Well, the truth is that there were so many organizations and people over decades

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that all made decisions that came together in a perfect, tragic storm.

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I'm Tatiana Bunch, and this is what led to the Grenfell Tower fire.

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Music.

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Now, I am diving into this episode with the assumption that you have listened

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to the first one I did, where I talked about phase one of the report,

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the victim's stories, and the initial beliefs on what caused the fire.

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If you haven't listened to it or are not at least somewhat familiar with what

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happened on the night of the fire and what was speculated about the cause,

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then I do suggest you go listen to that first and then come back.

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Otherwise, I'm diving right in.

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All sources can be found at occurrencepod.com, which is linked in the show notes,

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but I'm using the inquiry report and other very public and available information

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for this, but do your own research, form your own opinions.

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And without further ado, I want to emphasize that the failures with Grenfell

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Tower started back in the 1990s.

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Okay, so decades of failures within the government, in private companies,

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and in certification agencies.

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There were things ranging from communications issues to ignoring repeated warnings,

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failing to take action, all the way to clearly cutting corners.

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And it was all completely avoidable. The fire wasn't a one-off incident caused by one single error.

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It was the culmination of multiple failures at every level of the system.

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From 1991 up to the Grenfell Fire, there were several opportunities for the

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government to change course and stop the use of dangerous materials on high-rise buildings.

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For example, the 1991 Nosley Heights Fire and the 2009 Lackanell House Fire.

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Both should have led to major changes.

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No one died in the first one, and six people died in the 2009 fire.

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But the risks were clear, and each time the necessary changes were either delayed or ignored.

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In the 1991 fire, the firefighters said that the water literally bounced off

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the cladding of the building while they were trying to put out the fire.

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And it was made worse because the cladding fell onto them, and they had to control

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the fire on the building and then extinguish it on the floor too. do.

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The cladding installed at that building was a combustible polymer material,

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and the fire led to building regulations being updated to be more specific in

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the types of materials that were allowed,

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but the flammable cladding wasn't banned because it had already been classed

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as meeting British safety standards.

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So my understanding is that the UK uses the National Class Zero Fire safety

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standard, which was inadequate for evaluating cladding panels.

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It was used to measure a product's reaction to heat or fire,

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like how specific materials behave, but it doesn't test its combustibility,

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so it doesn't guarantee a material is flame resistant.

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It's considered old and outdated.

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It was introduced in 1991, and even though the Euroclass system was introduced

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in 2000, the UK kept the National Class Zero Fire Safety Standard in place.

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The inquiry made it clear that by 2016, the government knew about the risk posed

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by combustible cladding and insulation.

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But nothing changed. The worst part is that the government was warned by an

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Environmental and Transport Select Committee back in 1999. They said it shouldn't

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take a major fire with fatalities for changes to be made.

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And yet, it took Grenfell.

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But the issues didn't stop there.

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Over the years, there were several chances to clarify confusing fire safety

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standards that were in place, and the government knew were confusing.

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When they did take time to try and address things, it was vague,

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so it was still confusing, which they also knew. By 2016, the warnings about

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the insulation and panels used continued to grow.

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People in the industry were also becoming concerned about the safety of the

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materials, but there were still no meaningful changes made.

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The department responsible for building regulations was poorly managed.

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A junior official, given too much freedom, without enough supervision,

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mishandled these critical issues. Then, higher officials failed to intervene

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or ensure that safety concerns were actually being properly addressed.

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Now, as for how the highly combustible cladding, essentially petrol encased

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in metal, covered the walls of Grenfell Tower,

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one name you'll hear often in the inquiry is Arconic, the manufacturers of the

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Raynaud-Bond PE-55 panels used on the tower.

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These panels had a polyethylene core, a material known to burn aggressively when exposed to fire.

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Starting in 2005, Arconic knew

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about the fire risks, but kept that information hidden from the market.

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Instead, they claimed it had a safer fire classification than it actually did.

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Even after later testing showed that the Raynaud bond was unsafe in multiple forms.

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They just continued to sell it. But it wasn't just Arconic.

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Cellotex, the company that manufactured the insulation used behind the cladding, also played a part.

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It's called RS5000 and they knew they were supplying material that was combustible

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and unsuitable for high-rise buildings.

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And they didn't just make an honest mistake. They manipulated safety tests to

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get their product approved.

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They used fire-resistant boards in the test to pass it, but didn't disclose

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this in their reports or marketing materials.

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They falsely claimed that RS-5000 was the first insulation board to pass certain

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tests and suitable for high-rise buildings, even though they knew it wasn't.

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Then there's Kingspan, who also sold insulation called K-15.

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They claimed their product was suitable for high-rise buildings too,

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based on outdated and manipulated test results.

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They knew that there was a lack of detailed knowledge in the industry about

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fire safety standards, so they were able to make misleading claims about K-15's performance.

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For testing, they used modified versions of the insulation, which skewed the

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results, and they relied on fake certifications to sell it.

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Here's the thing. These companies knew. They knew their materials were dangerous

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and still went ahead and sold them.

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To have test results showing how dangerous a product is and continue to sell

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it without a warning, the inquiry describes this as, quote, systemic dishonesty.

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I'm thinking of another word for it, but how they were approved for use on high-rise

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buildings is another giant question mark.

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The inquiry found that the testing and certifications process was full of gaps.

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There's the building research establishment, which I'll call BRE,

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and the British Board of Agriment, I'll call it BBA.

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Both organizations trusted to ensure materials met safety standards and both failed to do their jobs.

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It's worth noting that the BRE was once a government body dedicated to fire safety research.

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It was highly respected in the construction industry for its expertise and was

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considered a leader on the national and international level.

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Around 1991, things started going wrong, and after that, the BRE's work on testing

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the fire safety of external walls had serious problems.

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There was unprofessional conduct, sloppy practices, and a lack of proper oversight.

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The reports turned superficial and missed important details.

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They didn't provide a full analysis, which made it seem like the fire safety

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regulations in place were effective.

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It's my understanding that, in part, had to do with regulations and policy rollbacks

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and deregulation and politics, but since that's not my country, I'm not touching that.

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But after the 1991 fire, the BRE realized that the small-scale tests used for

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the National Class Zero standards weren't good enough for seeing how external

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walls would behave in real fires.

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So they didn't notify anyone outside of their organization about the issues.

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Instead, they kept it to themselves. The BRE was privatized in 1997,

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so the government limited its role, which limited their access to any valuable

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experience or advice, to the point where investigations into fire safety were

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cut short before they were actually finished.

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But in 2001, the BRE didn't report on the large-scale tests that they did that

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showed the dangers of aluminum composite panels like the ones used at Grenfell.

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They didn't warn the industry. I mean, they didn't even publish the results.

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And the way that they conducted tests and kept records opened them up for manipulation by manufacturers.

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Like with Celotex and Kingspan, both of the companies behind the insulation.

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Well, Celotech had issues with their second test.

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So senior BRE staff advised that company and even Kingspan on how to meet safety

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standards, which obviously compromised BRE's integrity and independence.

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Overall, it came across like BRE was more interested in pleasing their clients

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and keeping their industry status than enforcing rigorous safety standards,

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which was in part because of the inadequate training with ERE staff in knowing

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their responsibilities.

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Meanwhile, the BBA, who is supposed to certify products and basically say,

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yes, this product meets safety standards.

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Well, they issued certificates of compliance for materials they hadn't fully tested.

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For example, with the Arconic Company, the one behind the Raynaud Bond cladding

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used on Grenfell, the BBA issued a certificate in 2008 that included false statements.

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It said that the product had a class zero surface, which is supposed to mean

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it's not very flammable.

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But the test results that they based the claim on weren't even the same version

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of product used on Grenfell.

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And instead of following up with Arconic for more information,

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they didn't. They just kept reissuing certificates without new data.

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And then with Kingspan's K-15 installation, the BBA allowed the company to dictate

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the terms of its certification.

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The BBA didn't even gather enough data to assess the product properly,

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but they still issued a certificate saying that it met buyer safety standards.

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By July 2013, the BBA was saying K-15 was a material of limited combustibility,

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but it wasn't because it was actually a phenolic foam product,

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which is highly combustible.

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The BBA should have known that, but it didn't.

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There's also the Local Authority Building Control, or LABC, which is another

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organization responsible for approving construction products.

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Well, the inquiry found that the LABC failed to thoroughly check whether the

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materials were safe for use on high-rise buildings over 59 feet or 18 meters tall.

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They allowed manufacturers to manipulate the certification process because they

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didn't question the claims made by companies like Kingspan or Celotex.

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They just accepted what they were told and issued certificates based on that.

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Now, part of that was because the review process wasn't strict enough.

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But another part of it was because the officers didn't always have the right

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knowledge to properly assess products.

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Then you have the National House Building Council, or NHBC, and they're responsible

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for overseeing building control and ensuring construction products meet safety standards.

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According to the inquiry, they didn't want to upset the industry by pointing

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out just how much combustible insulation was being issued in high-rise buildings,

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regardless of the fact that it clearly violated safety guidelines.

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They prioritized business relationships over public safety because they were

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too focused on keeping their clients happy.

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And lastly, of course, all of these organizations have someone overseeing them.

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That's where the UK Accreditation Service, or UKAS, comes in.

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It's supposed to make sure that organizations like the BBA and BRE are actually

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doing their jobs correctly.

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Unfortunately, they weren't doing enough to hold those organizations accountable.

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They were entirely too trusting of the companies they were accrediting and didn't

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follow up when things went wrong. The exact systems put in place to protect people failed.

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From the certification bodies to the regulators to the testing organizations.

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Safety and commercial interests cannot be allowed to mix unchecked.

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The certification process needs to be independent, rigorous,

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and focused on protecting people and not profits.

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Now, this clearly isn't just a story about failures with materials and regulations.

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It's also about the individual human experience of living in Grenfell Tower.

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The tenant management organization, TMO, remember them?

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They're responsible for managing the building and had a long-standing toxic

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relationship with many residents.

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People in the tower had been raising concerns for years about fire safety,

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the refurbishment, and their treatment. mint.

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They were ignored. The inquiry reveals a pattern of neglect,

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a lack of respect, and outright hostility from the TMO.

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Residents were belittled, their concerns were dismissed as nuisance complaints,

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and in the years leading up to the fire, the atmosphere between the residents

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and the TMO became, in the words of the inquiry, quote, toxic.

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And honestly, the relationship was broken and had been long before Grenfell was even refurbished.

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I touched on specific complaints of the residents on the other Grenfell episode,

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but the TMO was set up by the Royal Borough of Kensington and Chelsea, or RBKC, back in the 90s.

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The idea was that tenants could have more control over how their housing was managed.

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In theory, it sounds great, tenants managing their own homes.

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But in reality, it didn't work out that way, especially for the residents of Grenfell Tower.

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The TMO was responsible for all aspects of Grenfell Tower's management,

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including the fire safety and the major refurbishment that took place before the fire.

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They had a lot of autonomy, so they were in charge of making the key decisions

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about the building's upkeep and safety measures.

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Even before the fire, there were multiple warnings. In 2009,

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reports flagged that fire safety wasn't being properly managed across the TMO's housing portfolio.

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Still, barely anything was done to improve the situation.

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For example, the smoke ventilation system in Grenfell Tower.

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After a fire broke out in 2010 on the sixth floor, smoke spread throughout the

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building and the residents felt trapped.

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The TMO knew about these problems, and instead of fixing them quickly,

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they downplayed how severe of an issue it actually was.

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The smoke ventilation system wasn't fully replaced until 2016,

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six years later, and even then, it didn't work as intended.

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The TMO received multiple deficiency notices from the London Fire Brigade.

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One in particular, after a fire at Adair Tower in 2015, it exposed major issues

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with the fire doors and a lack of proper self-closing devices.

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These fire doors are crucial for keeping fires contained, and their failure

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directly put lives at risk.

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Still, the TMO didn't act quickly to resolve those issues, and when it was time

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to report the problem to the RBKC, they either downplayed or concealed the full extent of the issue.

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But the problems went even deeper.

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Robert Black, the TMO's chief executive, repeatedly failed to inform the TMO's

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board or RBKC about the critical fire safety concerns.

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Repeatedly, fire risks were identified,

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but the TMO leadership didn't communicate these risks properly.

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So both the TMO board and the council couldn't hold the organization accountable

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or ensure that the risks were addressed.

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Of course, the refurbishment used cheaper materials that were later found to

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be combustible, and the inquiry shows that the TMO and other parties involved

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didn't thoroughly check or challenge the safety of these materials,

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even though the risks are well known in the industry.

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This was in part because the refurbishment ran into budget issues early on.

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Instead of making sure things were done right, they shifted to saving money.

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The three organizations involved in the refurbishment didn't take fire safety

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as seriously as they should have because they didn't fully understand fire safety regulations.

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They assumed someone else was

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responsible for making sure the cheaper materials they chose were safe.

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And then you have the company the TMO brought in to be the architects of the refurbishment.

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That company brought in another company to draft the fire safety strategy.

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The company they brought in never finished it.

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It didn't check to see if the external wall, like the cladding,

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complied with fire safety requirements.

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They actually didn't even bother to visit the building.

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And then the architects that brought them in were supposed to make sure that

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the materials would comply with the safety regulations too, and clearly they didn't.

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And then you have the contractors and just honestly pretty much everyone involved,

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no one checked everything they should have all the way around.

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Now I mentioned the RBKC who had oversight of the TMO regarding fire safety

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and health matters, which was obviously severely lacking.

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Since RBKC was technically the landlord, it had ultimate responsibility for

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ensuring safety across the properties managed by the TMO.

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But instead, it put the TMO in charge of the day-to-day operations.

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Like, even with the fire safety issues raised by the London Fire Brigade,

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they were ignored or delayed in being handled.

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For example, the RBKC established committees for monitoring housing services,

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and they were supposed to scrutinize the TMO's performance in areas like fire safety,

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but somehow critical information about safety risks weren't given to those committees.

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So both the RBKC and the TMO boards were ill-informed and completely ineffective

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as far as oversight goes.

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RBKC also had a clear lack of strategy for handling large-scale emergencies,

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and they also failed to actually integrate the TMO into emergency planning.

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So both organizations were unprepared to respond effectively to disaster,

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especially one as large as the Grenfell Tower fire. Fire.

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Now, as for the response on the night of the fire, the London Fire Brigade,

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as brave as they were in risking their lives to save people,

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they were underprepared for a fire of this size.

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The inquiry hits on a chronic lack of training for dealing with high-rise fires,

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specifically that the London Fire Brigade's mistakes were not just about one night.

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They came from years of missed opportunities to improve their procedures,

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especially after the 2009 fire at Lackanell House.

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That was another high-rise building fire, and they struggled fighting it,

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and those same issues came back during Grenfell's fire.

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And then there was the poor communication between the control room and the firefighters on the ground.

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If you remember, the reinforced concrete was messing with the communication

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equipment between dispatch and the firefighters.

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Firefighters so dispatch would tell the command center one

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thing which they would try to relate to the firefighters and things

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would get lost in translation or they just wouldn't get

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through at all firefighters were being sent to areas where there was no one

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there because they moved to escape the smoke and dispatch couldn't get through

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to update the firefighters in time or they'd be told only one person was in

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an area but when the firefighters show up there's like like, eight people there.

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Well, the issues that they had were because the fire brigade hadn't modernized

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their equipment, and the firefighters weren't trained to effectively handle

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communication failures.

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They weren't given proper refresher training on handling calls from people trapped

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during a fire, so the people in the control room had to improvise when multiple

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calls came in from residents needing immediate help.

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I touched on a lot of what they messed up on in the other episode,

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but one thing the inquiry did make

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clear was that there were some officers that had

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knowledge of the dangers possessed by modern

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building materials but that information wasn't widely known within the brigade

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so a lot of firefighters weren't aware that high-rise buildings had this dangerous

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external cladding and I guess that can all just be chalked up to leadership

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failure and the fire brigade failing to ensure everyone was up to date in equipment,

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training, and learning from previous fires.

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Specifically, there wasn't actually a system in place to regularly evaluate

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the firefighters skills and the fire brigade didn't plan for a full evacuation

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of a high-rise building.

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They didn't train firefighters on how to safely evacuate large numbers of people.

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Their policy in high-rise buildings didn't even reflect national guidelines.

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So as you can see, there were widespread failures at literally every possible level.

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The residents of Grenfell knew things were unsafe in their building,

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but they were ignored, treated poorly, and ultimately cast aside.

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Now, there were 59 recommendations in the report on what should happen next.

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Some things have been passed since the fire, but actual change has been slow.

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One of the major recommendations was setting up a new construction regulator.

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It would be a single independent body that would oversee building safety,

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construction products, and the people working in the industry.

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It would have the ability to test and certify construction materials,

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oversee building controls, and license contractors who work on higher risk buildings.

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Those responsibilities are scattered in different agencies right now.

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It's how dangerous materials were able to slip through the cracks and end up on Grenfell Tower.

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So the idea is to centralize it. That way, the same people testing the materials

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are also the ones certifying it and licensing it.

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Now, in 2022, the UK government introduced the Building Safety Act.

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That does establish a building safety regulator, but a lot of the responsibilities

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are still spread out across different

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bodies, so a full consolidation of everything hasn't happened yet.

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Another recommendation was

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stricter oversight of construction products and better testing methods.

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Specifically, a product test library and more transparency from manufacturers

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to ensure that products used in buildings meet safety standards.

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It suggested that mandatory qualifications for fire risk assessors are implemented,

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along with health and safety strategies for higher risk buildings.

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There's also recommendations about a new regulator for fire engineers,

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and of course, an overhaul in how the London Fire Brigade is trained.

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For the London Fire Brigade, they want the firefighters and control room staff

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to have more comprehensive training focused on the dangers that come from combustible materials.

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They recommend regular assessments and refresher courses to keep all of the fire brigade up to date.

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They also recommend emergency planning for local authorities.

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It really stressed that local authorities need to be better prepared.

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They should have clear plans for dealing with mass evacuations and make sure

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that the plans are regularly reviewed and updated.

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Like I said before, some organizations have since made changes and others have

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been dragging their feet.

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Until concrete legislation is passed, I assume that the organizations being

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slow to change will continue to do so, and I'm not sure what it will take for things to be expedited,

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but the inquiry did hint on discrimination and inequality being a factor leading

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up to the fire, and definitely impacting the residents after the fire.

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Grenfell Tower was home to mostly working class, ethnically diverse people.

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Many were Muslims celebrating Ramadan at the time of the fire.

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Leading up to the fire for years, the TMO and RBKC ignored the residents' repeated

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complaints about safety and other building concerns.

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And I think it's safe to say that would not have happened if a wealthier or

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different demographic of people were living there.

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After the fire, the residents were discriminated against and abandoned.

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Those celebrating Ramadan were not accommodated by the RBKC.

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People practicing Ramadan fast from sunrise to sunset, and very little effort

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was made to recognize this and to provide food and support in a culturally appropriate

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way for those specific residents.

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Local volunteers and community organizations had to step in to help because

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official support was like non-existent.

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And honestly seeing how this group of people have been treated in recent weeks

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in the UK I don't think the inquiry went far enough in calling out that aspect

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of this tragedy but I think that particular factor plays a huge part in why change has been so slow.

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It plays a part in why the fire happened in the first place and beyond that

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with quite literally every level failing of government,

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private, and individual protections I'm speechless and I don't think I I can

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stress enough how thorough and extensive this report was, and that's why it

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took so long for them to put it out.

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I think they did a great job of simplifying the vast amount of information that

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they had to sift through and understand because they would discover one issue

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and then have to go back and look at what led to it and then realize,

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oh, well, that happened because this happened like 10 years ago.

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And that happened 10 years ago because this happened over here.

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I mean, this was literally the perfect storm of just failure on top of failure on top of failure.

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But I do think they should have done more as far as recommendations on social

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housing reform and leaseholder and tenants' rights.

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Because as far as I can tell, that's non-existent. And there are people calling

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for national oversight to enforce the organizations

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to follow the inquiry recommendations, which I support. court.

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But I digress. We will have to wait until the end of 2026 or early 2027 to see

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if criminal charges will be drawn up.

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Some people are calling for financial charges to the companies responsible,

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but others are calling for jail time for at least manslaughter.

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Both should probably be done, but honestly, anything short of something significant

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and substantial will not stop what's happening or prevent this from happening again.

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If the consequences aren't severe enough, something like this unfortunately

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might happen again in the future because there will be no incentive to change.

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I mean, we're like seven years on from the Grenfell Tower fire and there are

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still buildings with that dangerous combustible cladding on them.

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It's crazy, but I guess we'll see what happens.

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Stay safe, and I'll be back this Thursday for the regularly scheduled episode.

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Music.