This second part into the fire has just been published. This second part into the Fire Hasjust been published. The report now runs to 1,700 pages. We arejust about report now runs to 1,700 pages. We are just about to hear from the chair. Let us listen in. My the chair. Let us listen in. My report on that series of events was published on the 30th of october 2019. In the second phase of the inquiry, the panel has been investigating the underlining causes of the fire, with a view to identifying when mistakes were and our terms of reference, and partly because, as our investigation has progressed, we uncovered many more matters of concern than we had originally expected. As we discovered, it is not possible properly to understand the causes of the fire without understanding the way in which knowledge of the materials and methods of construction employed in the Refurbishment Development over the course of time. But the government and others learned about them, and how the regulations and guidance relating to their use developed during the same period. The information obtained in that part of our investigation provided the background to our examination of the refurbishment itself and the various decisions taken in the various decisions taken in the course of it. Particularly in relation to the selection of materials in addition, it has been necessary for us to examine the way in which Fire Safety at Grenfell Tower was managed, including the arrangements forFire Risk arrangements for Fire Risk assessments arrangements forFire Risk assessments and the response to them. As well as the relationship between the Tenant Management Organisation and the residence of The Tower. The Firefighting Operations of the London Fire brigade were considered in detail in my first report but a number of questions relating to Organisation And Training could not be answered at that stage and were deferred for consideration in phase two. Also deferred to phase two research questions relating to the development of the fire, including the relative contributions of the different materials used in the cladding. Another important aspect of our terms and reference was to investigate the response of the authorities to the emergency. Finally, but most importantly, it was necessary for us to investigate, inasmuch detail as the evidence would allow, the circumstances surrounding the deaths of those who perished in the fire. The report we are publishing today contains our findings on all these and other matters. However, the simple truth is that the deaths that occurred were all avoidable and those who lived in The Tower were badly failed over a number of years and in a number of different ways by those who were responsible for ensuring the safety of the building and its occupants. They include the government, the Tenant Management Organisation, the royal borough of Kensington And Chelsea, those who manufactured and supplied the materials used in the refurbishment, those who certified their suitability for use on high rise buildings, the architect, the Principal Contractor, and some of its subcontractors, In Particular, harley, Kirk And Bus ads. Some of the consultants come In Particular the fire engineer, warrington fire, local authorities Building Control department, the London Fire brigade. Not all of them bear the same degree of responsible at eight for the eventual disaster, but as our report shows, all contributed to it in one way or another, in most cases through incompetence, but in some cases, through dishonesty and greed. The feelings can be traced back over many years and our efforts to get to the badham of what went wrong and why account for the length of the report and the length of the report and the time it has taken us to produce it. However, if an inquiry of this kind is to produce anything of value, it is necessary for those who can influence the future direction of the Construction Industry, the Fire And Rescue service is, the Fire And Rescue service is, the management of Fire Safety in buildings and resilience planning, to understand exactly where mistakes were made and how they can be avoided in the future. The report is divided into 1a parts, broadly by reference to related subjects. Some parts contain several chapters. Some, only one. As with the Phase One report, it begins with an introduction, followed by an Executive Summary. Although the Executive Summary. Although the Executive Summary runs to 2a pages, the length of the report means that it can touch on only the most significant elements of our conclusions. However, it should assist readers in finding their way around the report. Part two describes significant events that provided the background to the fire. It begins by explaining how the regulations and guidance in force at the time of the refurbishment came into being and the way in which the reaction to the fire of materials used in the construction of modern high rise buildings was tested. We then consider the involvement of the Government Involvement of the government in the form of the then department for communities and local government, the way in which it sought to monitor the causes of fires when they occurred and most importantly, the Warning Signs that were emerging from as early as 1991, that some kinds of materials, In Particular Aluminium Composite Material panels with unmodified polyethylene because, were dangerous. We found there was a failure on the part of the government and others to give proper consideration at an early stage to the dangers of using combustor materials. 0n the walls of high rise buildings. That including failing to amend in an appropriate way the Statutory Guidance on the construction of external walls. That is where the seeds of the disaster or soon. That is where the seeds of the disaster orsoon. In that is where the seeds of the disaster or soon. In part three, we set out our findings about the Testing And Marketing of the main products used in the refurbishment. The panels, the refurbishment. The panels, the 5,000 insulation and a small amount of Kingspan K 15 insulation. We discovered there had been systematic dishonesty on the part of manufacturers involving deliberate manipulation of the Testing Processes and calculated attempts to mislead purchasers into thinking that what were combustible materials complied with the provisions of the Statutory Guidance that advised against their use. That dishonest approach to marketing was compounded by the failure of two of the bodies that provided certificates of compliance with the Building Regulations and Statutory Guidance. The british board of agri more and local Authority Building Control to scrutinise the information provided to them with sufficient Care And Exercise the degree of Rigour And Independence that was to be expected of them. The Tenant Management Organisation was at the heart of events leading up to the fire. In part four of the report, we make our findings about its relationship with the residents of Grenfell Tower. We found that the organisation was badly run and failed to respond to couldn systems of its treatment of residents contained in independent reports produced in 2009. It is clear that for some years before the fire, relations between the tmo and residents were marked by distrust, antagonism and increasingly bitter confrontation. We find that for the tmo to have allowed the relationship to deteriorate to such an extent reflects a serious failure on its part to observe its basic responsibilities. Part five of the report is concerned with the report is concerned with the management of our safety at the management of our safety at The Tower. Again, we find that The Tower. Again, we find that the residents were badly let down. The picture is one of a persistent failure to give sufficient importance to the demands of Fire Safety, particularly the safety of vulnerable people, and a failure on the part of the council to scrutinise that aspect of the organisations activities adequately. Part of the reason for that was the failure of the Chief Executive, robert black, to ensure that the board of the tmo and the council were kept properly informed of matters affecting Fire Safety. That was despite periodic expressions of concern by the London Fire brigade about compliance with the Fire Safety order, all of which should have been drawn to their attention. The Tmos Failure to attach significant importance to Fire Safety is illustrated by its reliance on a single person, carl stokes, as far as for its entire estate. Despite his lack of qualifications and experience, by its failure to carry out necessary remedial work, identified in a Fire Risk assessments promptly, by its failure to provide measures to mitigate the absence of an effective smoke ventilation system, and by its failure to introduce appropriate arrangements for inspecting and maintaining Fire Prevention systems, In Particular Self Closing devices on the entrance doors to individual flats. In addition, the tmo failed to maintain a reasonably accurate record of those residents of The Tower who are vulnerable for one reason or another, and likely to need help to escape if a fire occurred. Part six of the report contains our findings about itself and again, the picture is disturbing. First, the regular Tree Context in which the work was carried out was in our view, unsatisfactory because the Statutory Guidance which was treated by many in the Construction Industry, including those engaged on the refurbishment, as containing a sufficient statement of what was required, did not make it clear enough that it was subject to the overriding requirements of the Building Regulations. That was a particular problem in relation to the Rain Screen panels which, although they satisfied the requirement in the guidance for a material with a class zero service, contained a highly combustible core. But thatis highly combustible core. But that is the beginning. The Tenant Management Organisation, as the client, manipulated the process of appointing an architect to design the refurbishment in order to avoid the need to invite open tenders for the architectural services. It did so because it wanted to appoint Studio E, the architect for the existing Academy And Leisure centre project, despite the fact that it had no experience of Over Cladding a high rise building. That turned out to have significant consequences because Studio E failed to recognise as a reasonable competent architect should have done, that the insulation and Rain Screen chosen for the refurbishment were combustible and unsuitable for that purpose. Acm panels were chosen as the Rain Screen to keep down the cost. Neither the Principal Contractor nor its Cladding Subcontractor was aware of the properties of the material specified for use in the refurbishment, although harley, as a Specialist Subcontractor dealing with cladding, should have been, and is the Principal Contractor had its own responsible to to ensure the materials were suitable. 0ne ensure the materials were suitable. One of the problems that afflicted the refurbishment was a failure on the part of all concerned to understand where responsibility for any particular decision lay. That was especially the case in relation to the choice of the Rain Screen. The generally prevailing view was that since Aluminium Composite Material panels had been used on other buildings without apparent problems, they were suitable for use on The Tower. But No One was prepared to accept responsibility for having chosen them and when questioned, everyone who was asked said that Someone Else had been responsible for ensuring that they were suitable. We find that Studio E, Ryden And Harley altogether unacceptable casual approach to contractual relations. None of them engaged in the project, understood the relevant Building Regulations, Statutory Guidance or such guidance from Industry Sources as was then available. That might not have married quite so much if proper advice had been given from a competent and experienced far engineer, or if Building Control had performed its task properly stop in fact, the Tenant Management Organisation did instruct them to produce a Fire Safety strategy for the establishment which should have included advice on the effect of the Over Cladding and the compliance of the external walls with a functional requirements of the building were galatians. Ex over produced three versions of a Fire Safety strategy but each version was stated to be a draft and was incomplete because it did not deal with that particular question, which it said would be covered in a future issue of the report. It was clear, therefore, that the Fire Safety strategy was incomplete, but No One asked them to finish their work, nor did anyone provide it with details of the proposed cladding to enable it to do so. X over itself failed to ask for the missing information or to complete the work it had been instructed to carry out. The failure to obtain a final report was probably critical because if the company had considered the proposed cladding, it should, and probably would have identified the fact that the insulation and the Rain Screen did not comply with the Statutory Guidance or, more importantly, the Building Regulations. In part eight, we set out our findings on the Management And Training of the London Fire brigade in the years leading up to the fire. That part of our investigation is represented a continuation of the work started in Phase One in which i described the response of the London Fire brigade on the night. I was critical of certain aspects of that response, In Particular the way in which the Control Room handled calls from people trapped in the building, and the actions of some of the incident commanders, who had not been properly trained to deal with the fire of that nature. That made it necessary for us to examine the London Fire brigade� s Management And Training in the period leading up training in the period leading up to the fire, as well as the way in which it made use of the information available to it. In our report, we find there were deficiencies in the Organisation And Management of the Control Room, the training of Control Room officers, and in the Commissioning And Delivery of training to operational crews. In particular, in relation to incident command. There were also deficiencies in the collection of information needed to enable crews to prepare effectively to respond to fires in individual buildings. The primary cause of those problems was a chronic lack of effective leadership, combined with an undue emphasis on process and an attitude of complacency. We have also returned to investigate some aspects of the Firefighting Operations on the night of the fire, an which i was unable to make findings in Phase One, In Particular, problems with communications and the supply of water. I shall return to port nine of the report in a moment but for now, i moved to part ten, in which we examine the Authoritys Response to the fire. 0nce the Authoritys Response to the fire. Once again, we have found that those who lost their homes as a result of the fire were badly let down by the organisations that should have provided the support they desperately needed. The primary responsibility for that lay with the council, which, as a category one responder under the civil contingencies act, should have had plans in place to enable it to respond effectively to the emergency. In the event, however, it had failed to put in place suitable plans or to provide the training to its staff that was required to enable it to respond effectively to the situation it faced. In addition, its Chief Executive was ill suited to taking control of what was undoubtedly a very serious challenge. The council did not have the capacity to identify those who needed accommodation and other important forms of assistance, nor did it have arrangements in place for indicating with those affected by the disaster, or the wider public. As a result, it was not capable of meeting the immediate needs of those who had been displaced from their homes with food and shelter. In the end, it was a local voluntary and community organisations that filled the gap by providing rest centres and temporary shelter. The london wide resilient structures that were intended to enable the capital to respond to an emergency affecting more than one borough did not operate effectively, partly because they were not designed to provide a central direction to the response, and partly because the royal borough of Kensington And Chelsea did not seek assistance promptly. In the event, the government, in the form of a senior official in the department for communities and local government, broke an arrangement under which the experienced Town Clerk of the City Of London took control of the operation. An important chapter of this part records of the evidence given by those who were personally affected by the fire. We are acutely aware that giving evidence, particularly if in evidence in public, was a difficult and daunting experience. We should therefore like to thank all of those who contributed to our investigations by giving evidence, both in the form of witness statements, and being willing to speak about their experiences in public. By doing so, they ensured that we received the fullest possible account of the events that unfolded. In parts 11, 12 and 13 of the report, we deal with a number of different matters, including the experiments carried out by the two professors on the materials used in the refurbishment. They confirm that the bond on composite Material Annals with the primary reason for the fires devastating progress. Part 1a contains our recommendations. Although some steps have already been taken to respond to the many failures that we have identified, we think that more can, and should be done, to bring about a fundamental change in the attitudes and practices of the Construction Industry. 0nly such a change can ensure that in future, buildings in general and higher Risk Buildings In Particular, are safer for those who live and work in them. We think that in different ways, implementation of our recommendations will improve far safety, particularly in high rise buildings, and ensure that dangerous materials cannot be used in construction in the future. They will also improve the efficiency of Fire And Rescue services nationally. 0ur Rescue services nationally. Our recommendations include, but are not limited to the following, the appointment of a Construction Regulator to oversee all aspects of the Construction Industry, ringing responsibility for all aspects of Fire Safety under one government department, the establishment of a body of professional fire engineers, properly regulated and with protected status, and the introduction of mandatory Fire Safety strategies for higher Risk Buildings, a Licensing Scheme for contractors wishing to undertake the Construction Or Refurbishment of higher Risk Buildings, the regulation and mandatory accreditation of Fire Risk assessors, the establishment of a college of fire and, to provide practical, educational and managerial training to Fire And Rescue service is, and the introduction of a requirement for the government to maintain a publicly accessible record of recommendations made by a select committees, coroners and public inquiries, describing the steps taken in response to them, or its reasons for declining to implement them. I now return to part nine of the report, which is the most personal part, and contains the most difficult reading. It contains a detailed account of the circumstances surrounding the circumstances surrounding the deaths of those who perished in the fire. I did not refer to it earlier because it seemed to me to be fitting to end these proceedings as they began in may 2018, with a reminder that the fire at Grenfell Tower was above all, human tragedy, in which many lives were lost, families were torn asunder, homes were destroyed, and a community was shattered. The detailed reconstruction we have provided will be, for many, one of the most important parts of our report. Although it may make painful reading, those who lost relatives and friends naturally feel the need to know as much as possible about their loved ones� s last moments. I said on many occasions that i hoped we would find sufficient facts to satisfy the corner of the circumstances surrounding their deaths and avoid the need for any further proceedings. I am now able to say that we have been able to make detailed findings about the circumstances in which people died, including calls made to the emergency services, the transfer of information from the Control Room to the incident ground, the recording of that information on its way to, and at the bridge head, the steps taken to to, and at the bridge head, the steps Ta Ken to rescue to, and at the bridge head, the steps taken to rescue those who were trapped. We are satisfied that all those who died in the building were overcome by toxic gases produced by the fire and with expert assistance, we have been able to establish a reasonably accurate time of death in each case. We are satisfied that all those whose bodies were damaged by the fire were already dead by the time it reached them. In a moment, my fellow Panel Members wished to add some comments of their own. Before they do so, however, i should like to thank the inquiry team, without whom it would not have been possible to carry out an investigation of this kind. It would be invidious to single out individual names for mention on this occasion because everyone involved, whatever their particular tasks, has played an essential part in enabling us to do our work. With their help, we have followed up many lines of inquiry, some of which lead to surprising revelations, and have collected and digested and have collected and digested a huge number of documents and statements, not to mention hearing many days of oral evidence. All those who worked for the inquiry over the years or named in an appendix to the report, and we them a deep debt of gratitude. I now invite my colleague to say a few words. Good morning. Before ijoined the inquiry panel, i spent the inquiry panel, ispent nearly the inquiry panel, i spent nearly 30 years as an architect. In that role, i developed a particular interest in health developed a particular interest in health and, Fire And Accessibility matters. Returning home from a Holiday Injune returning home from a Holiday Injune 2017, i flew over returning home from a holiday in june 2017, i flew over West London in june 2017, i flew over West London and saw the Burning Tower london and saw the Burning Tower in london and saw the Burning Tower in the early hours from the air~ tower in the early hours from the air~ as tower in the early hours from the air. As with so many others, the air. As with so many others, this was a profound shock, others, this was a profound shock, first of course, as a human shock, first of course, as a human response, but also as a professional who had spent their professional who had spent their career working to make buildings their career working to make buildings safe. Throughout this inquiry, buildings safe. Throughout this inquiry, we have been determined to find out how such a disaster determined to find out how such a disaster was possible. And what a disaster was possible. And what needs to be done to save lives what needs to be done to save lives in what needs to be done to save lives in the future. As Sir Martin lives in the future. As Sir Martin hasjust summarised, we have Martin Hasjust summarised, we have found many feelings across a wide ranging of institutions, organisations and individuals that organisations and individuals that spanned many years. Which, together, that spanned many years. Which, together, have led to the terrible together, have led to the terrible fire at Grenfell Tower~ here they include many failures ofthe here they include many failures of the construction here they include many failures of the Construction Industry,. Of the Construction Industry, my own of the Construction Industry, my own sector, which is where i will focus my own sector, which is where i will focus my comments on today will focus my comments on today. Since the fire, the government has passed the building safety act. The act is welcome, building safety act. The act is welcome, but we need to go further~ welcome, but we need to go further. 0ur Report identifies what further. 0ur Report identifies what we further. 0ur Report identifies what we think is needed to make sure the what we think is needed to make sure the legacy of grain fell is real, sure the legacy of grain fell is real, and brings about testing is real, and brings about lasting and Progressive Change grenfell. 0ur grenfell. Our recommendations place new burdens recommendations place new burdens and responsibilities on People Burdens and responsibilities on people and organisations and i make people and organisations and i make no people and organisations and i make No Apologies for that. Put simply, make No Apologies for that. Put simply, if make No Apologies for that. Put simply, if you work in the Construction Industry and you do not
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