Wednesday, October 5

‘A merry-go-round of buck-passing’: inside the four-year Grenfell inquiry | Grenfell Tower inquiry

A crime had been committed. That was clear as dawn broke on the burning wreck of Grenfell Tower, in west London, on 14 June 2017. As the death toll climbed, the obvious questions arose: who was responsible? How did a council block in the UK’s richest borough, refurbished just a year earlier, come to be engulfed in flames that swept from its fourth to 24th floor in less than 30 minutes? Why did 72 people die?

“We need to have an explanation of this, we owe that to the families,” said prime minister Theresa May on 15 June 2017. She reached for an investigatory method beloved of governments keen to be seen to be doing something after devastating scandals, disasters and wars: the public inquiry.

The purpose of a public inquiry is to find out what happened and why, and to prevent whatever happened from happening again. Since 1997, there have never been fewer than three public inquiries running at any one time. They tend to be chaired by retired, dependable, white male judges. Between 1990 and 2017, there were more chairs called William or Anthony than women (the forthcoming Covid-19 inquiry chaired by Baroness Heather Hallett is a rare exception). For Grenfell, Theresa May chose a Martin.

Sir Martin Moore-Bick, a retired appeal court judge expert in contract law, picked as his lead counsel, Richard Millett QC, son of a law lord. Millett’s job would be to cross-examine witnesses and marshal a legal army of 39 barristers and 10 solicitors to comb through 320,000 documents. Moore-Bick would have to make sense of it all.

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As survivors and the bereaved mark the disaster’s fifth anniversary, the inquiry hearings are finally nearing their end. It has been a painstaking and expensive – £149m and counting – attempt to figure out who is responsible, and why. While the public inquiry will not determine civil or criminal liability, Scotland Yard detectives will weigh its evidence when they consider whether to press charges.

Reporting on the inquiry since its first day, I have sometimes worried that with 27 commercial organisations and eight public bodies tangled up in the Grenfell story, the inquiry will never reach a clear answer. In a 21st-century economy obsessed with outsourcing risk, witness after witness has repeated that key decisions were “someone else’s responsibility”. Fault was found with almost every player, from the architect and the manufacturers to the fire brigade and the building inspectors.

But conclusions that share blame and point to system failure will offer the bereaved little satisfaction. Did no one working on Grenfell grasp the possible consequences of their decisions? The suggestion that the complexities of testing materials and following safety standards appear to have overwhelmed the professionals involved in a £10m reclad of a council tower block was unnerving.

More disturbing still was how familiar much of the evidence felt from our own working lives. When witnesses, presented with their own email trails, admitted that they “didn’t open the attachment” that contained some vital instruction or information, it was not a shock. This is business in the 21st century.

When the inquiry publishes its final report in 2023, it may find that the fire was a result of the way we work – deluged with unread emails, constantly overstretched, walled off from the consequences of our actions, barely understanding the whole system. This may ultimately be more chilling than a guilty verdict directed at a person or company. It would be an indictment of our whole economy.

Phase one: the night of the fire

At 11am on 21 May 2018, in the ballroom of the Millennium Hotel in west London, the inquiry commenced with eight days of commemorations for the dead. Addressing the gathered survivors and the bereaved, Millett gave a sparse timeline of the fire. It broke out just before 12.54am. By 1.29am, flames had risen to the top floor of Grenfell’s eastern facade. At 8.07am, the last surviving resident escaped. Millett promised that the inquiry would examine the physics of the blaze and the firefighters’ response, as well as the decisions that had led the building’s exterior to be clad in flammable material.

“But Grenfell is not a lawyer’s argument or a scientist’s experiment,” Millett said. “Grenfell was home … a place of refuge … a joined-up community whose members worked, played, prayed and lived together … And many of them died together.”

The next eight days were extraordinarily painful and moving. There were poems, eulogies, and videos. The family of Mohamed “Saber” Neda, a Kabul-born chauffeur who had lived on the top floor since 1999, played his last phone message. “Goodbye,” he said in Dari. “We are now leaving this world. Goodbye. I hope I haven’t disappointed you. Goodbye to all.”

Betty Mendy, sister of Mary Mendy, who died with her daughter, the artist Khadija Saye, wept as a statement was read out from a cousin: “I hate night-time because night brings silence, and silence brings tears of sadness, because that’s when I start to remember the blaze of fire.” On the second day, 20 or more survivors left the room as a video about the deaths of six members of the Choucair family showed traumatic images of the tower on fire and residents trapped behind windows. Watching the video, an audience member collapsed.

A Grenfell memorial site in 2021. Photograph: Graeme Robertson/The Guardian

On 4 June 2018, the inquiry moved to a new venue, a room in a neo-Gothic Victorian building in London’s legal district, Holborn. Counsellors were present in case survivors needed support, but they were far outnumbered by the lawyers for the companies and organisations under investigation. “We hope,” said Millett in his opening statement, “that core participants resist the temptation to indulge in a merry-go-round of buck-passing.”

The inquiry was divided into two phases. Phase one, which took 16 months, was dedicated largely to the events of just seven hours: the period when the fire was blazing and rescue operations were underway. It heard survivors’ accounts of dense black smoke filling their flats “as if it was shooting in from a hose” and the heartbreaking final 999 calls of people including Mariem Elgwahry, 27, sheltering with six others in a top-floor flat describing how flames were rising and about to burst through their windows. “We’ve got nowhere to go,” she said. “We’re stuck”. They all died.

Moore-Bick’s initial 800-page report, delivered in October 2019, strongly criticised the response of the London Fire Brigade (LFB), suggesting that it should have recognised sooner that the fire was out of control, reversed the “stay put” instructions it had initially issued to residents, which had been based on the presumption that fire could not spread throughout the building, and instead ordered an evacuation.

In the wake of the phase one report, Dany Cotton, commissioner of the LFB, quit. She had angered the bereaved by telling the inquiry she “wouldn’t change anything we did on the night”. But many survivors were unsatisfied with the blame being placed on the fire brigade. Many firefighters had shown bravery. Wasn’t the bigger crime wrapping the tower in cladding that burned like petrol?

Phase two: The cladding and ‘horse meat masquerading as beef lasagne’

It was phase two, which began in January 2020, that the bereaved hoped would give them the answers they needed: from the council, the builders, the companies that made and sold the combustible cladding panels, and the fire safety “experts” who had approved them.

Millett began with bad news. With minor exceptions, every written statement he had received from participants in the inquiry sought to explain how “what happened was, as each of them would have it, someone else’s fault”. To the Grenfell survivors, it was a familiar refrain. Many had spent years before the fire having their concerns dismissed as someone else’s responsibility by the very same organisations that were now under investigation. The “merry-go-round of buck-passing” was spinning.

Yet the mountain of emails, spreadsheets and reports mined from these organisations’ servers painted a different picture. The inquiry would hear that, in 2016, two employees of the insulation manufacturer Kingspan had a jokey text exchange about the claims it was making for its material’s fire performance. One said: “Alls we do is lie in here.”

In late 2020, after a four-month delay because of Covid-19, the inquiry began its examination of the companies that supplied the materials used in Grenfell’s lethal cladding system. As the days passed, the hearings became increasingly infuriating for the bereaved, as witness after witness seemed to struggle with memory and insisted someone else was responsible. Jonathan Roper, who worked for Celotex, the company that made most of the flammable insulation foam used in the 2016 recladding, was a rarity. He spoke candidly about the strategies, employed in the name of profit, that contributed to the use of dangerous materials on high-rise buildings.

Jonathan Roper, a former assistant product manager at insulation firm Celotex, giving evidence to the Grenfell inquiry in November 2020.
Jonathan Roper, a former assistant product manager at insulation firm Celotex, giving evidence to the Grenfell inquiry in November 2020. Photograph: Grenfell Tower Inquiry/PA

In May 2012, Roper, then 22, had graduated in business studies from the University of East Anglia, and just weeks later arrived at Celotex for his first job. He had no training in building regulations and knew nothing about insulation. The firm was soon taken over by French multinational Saint-Gobain, which was demanding an increase in profits, 15% of which was to come from new products.

The plan was to simply rebrand the rigid foam insulation panels it already made and target the high-rise housing market, which was worth around £10m a year. Celotex wanted Grenfell as a “case study”. Grenfell, a 24-storey, 40-year-old tower, was going to be wrapped in a cladding system to improve its thermal performance and appearance.

The method, widely used on new and refurbished blocks, involved fixing boards of 10cm-thick rigid foam insulation to the original concrete walls and overcladding them with rainscreen sheets pre-fabricated from thin aluminium sandwiched around a core made of a plastic called polyethylene. These sheets are known as ACM PE (aluminium composite material with polyethylene).

Part of Roper’s job – his annual bonus depended on it – was to assure the market that Celotex’s product, known as RS5000, was safe to use like this. The difficulty was that while builders prefer to use plastic foam boards because they can be cheaper, thinner and easier to install than non-combustible mineral wool, they also burn and release hydrogen cyanide, a gas more toxic than carbon monoxide. Celotex would need to reassure builders that using their product would not break safety regulations.

Roper began by looking at how Celotex’s main rival, Kingspan, had managed to get its insulation certified for use on tower blocks. Kingspan, which provided 5% of the insulation on Grenfell tower, had secured a large slice of the foam-insulation market, the inquiry heard, by mastering England’s byzantine regulatory system for building materials. For years, official guidance had simply banned the use of combustible insulation on tall buildings. This was a safety-first approach – after all, upper storeys were hard to escape from and fire brigades were usually not equipped to reach higher floors.

But in 2006, in response to manufacturers’ lobbying and a wish to cut carbon emissions through better insulation, the government had permitted the use of material with limited combustibility in specific types of constructions, which had to be proven safe in full-scale tests. These tests, often conducted at the Building Research Establishment (BRE) in Watford, involved mocking up a section of wall to scale, and setting fire to it under laboratory conditions.

This testing system was deeply flawed. The full-scale tests were complex; the results could be misinterpreted; the certificates were issued by a third body and could be drafted in ambiguous ways. All this meant that it was possible to make, market and sell material that was dangerous – but that seemed, on paper, totally safe.

In 2006, Kingspan changed the chemical composition of its leading insulation, Kooltech K15, but continued to sell it on the basis of a previous test. In 2007, a full-scale test of the new version became a “raging inferno”, said an internal report. (At the inquiry, Kingspan’s lawyer played this down, citing a test witness who did not agree the fire was “spectacular”, and said there was no scientific evidence to show its fire performance was any worse than the previous version.)

But Kingspan continued to sell the new version for use on hundreds of high-rise residential blocks in the UK and obtained certificates that said the new product could be safe on tall buildings if used in specific combinations with other materials. Kingspan said it should have done a fresh test but didn’t in the “honest belief that the change in technology would not make any material difference to the fire performance” and it conducted a test after the Grenfell fire which supported that.

By autumn 2015, the inquiry heard, Kingspan had sold K15 for use on at least 230 UK high-rise blocks. This was the market Celotex was chasing.

In his evidence to the inquiry, Roper said that he had tried to warn company bosses that their product was not safe to use behind most types of cladding “because in the event of a fire, it would burn”. But he had come to think they “wanted to launch into this [high-rise residential] market regardless”. It made him very uncomfortable.

In February 2014, Roper had stood alongside the BRE’s “burn hall” manager, Phil Clark, for a first test of Celotex’s insulation in a full-scale wall. A big clock ticked in front of the rig. If the flames got to the top within 30 minutes it was bad news. It failed in 26 minutes.

For the retry, Celotex did something shocking. It included bands of fire-retardant magnesium oxide board at strategic intervals to slow the spread of flames through the mocked-up wall. The material was concealed behind the exterior cladding panel and would be invisible to onlookers or in photos. “The rig was being over-engineered to achieve a pass,” said Roper, and pass it did.

The inquiry asked how Celotex could have done this without the BRE realising. It turned out Celotex arranged for the materials to be delivered to the BRE and supplied its own contractor to put up the test structure. Surprisingly, this was in line with normal practice. The test was then overseen by BRE technicians.

On day 71 of the inquiry, Roper told Millett that he was “not in any doubt” that Clark, the burn hall manager, knew what was being tested. Questioned three months later, Phil Clark denied any knowledge of Celotex’s ruse. “We’re not there to police necessarily every nth degree of what they’re doing there,” he told the inquiry. He said he couldn’t recall any magnesium oxide panels being delivered, and speculated that the delivery note “may have got lost”. While he normally knew which materials were involved in a test, “if you’ve got somebody who’s going out of their way to deceive, then there was a possibility they could do that”.

The true independence of the BRE, which charged manufacturers £25,000 a time to conduct full-scale fire tests, was frequently examined at the inquiry. “We have a lot of clients who spend a lot of money with BRE,” Stephen Howard, its director of fire testing told Millett. “We don’t wish to upset any of them.” The BRE told the inquiry its testing complies with British standards and that companies testing materials are contractually bound to provide accurate information. The BRE had been deceived by Kingspan and Celotex, it claimed, and rejected “any suggestion that it was complicit” in either Kingspan or Celotex’s “misleading promotion” of their products.

Lawyers for the bereaved saw it differently, and accused the BRE of acting as “a product champion, opening the gateway to sales for these deadly materials”. The whole certification process was “positively dangerous since it creates a veneer of respectability which, in some cases, serves to conceal test results obtained by dishonest testing,” they said.

Celotex admitted that a number of staff had engaged in “unacceptable conduct” but said that its current management only learned of this after Grenfell. The company said it has since changed its procedures and culture. Celotex also insisted there was no evidence the professionals working on Grenfell’s cladding had been misled by its product literature “in any relevant respect”, and said that the BRE knew about the fire-retardant boards. It said that when it ran tests of the insulation used just as the marketing brochures suggested it had initially been tested, it found it could be safely used, at least according to building regulations at the time.

In the winter of 2014-15, preparations for the recladding of Grenfell Tower were in full swing and the refurbishment team agreed to buy 660 of the panels – at close to a 50% discount. The inquiry had found the foam insulation “contributed to the rate and extent of vertical flame spread”. Simon Crawford, one of the architects on Grenfell, later described it as a case of “masquerading horse meat as beef lasagne”.

The combustible panels: “we have to keep [this] VERY CONFIDENTIAL!!!!”

Two years and nine months into the inquiry, in February 2021, the spotlight shifted to Arconic, a multinational giant that, among other things, makes aluminium sheeting for safety-conscious aerospace companies such as Airbus and Boeing. Its French subsidiary, Arconic Architectural Products SAS, had made and supplied the plastic-filled panels on Grenfell tower that Moore-Bick’s interim report had judged as the “principal reason why the flames spread so rapidly”. How had Arconic come to sell material for housing that burned so easily?

Five of Arconic’s key executives were called for questioning. To the dismay of the bereaved, three did not show up, invoking an anachronistic French law that can prohibit French citizens from disclosing commercial information to foreign judicial proceedings. There was nothing the inquiry, or the British foreign office, could do. Even the French government said it didn’t believe the law applied, but still the executives didn’t come.

Key among the absentees was Claude Wehrle, the firm’s head of technical sales support. In 2009, according to disclosed emails, he shared with colleagues images of a burning tower in Bucharest “to show you how dangerous PE [polyethylene] can be when it comes to architecture”.

In 2010, Wehrle had told a sales colleague that when PE panels were formed into a cassette, as they were at Grenfell, they were combustible. He added, “we have to keep [this] VERY CONFIDENTIAL!!!!” Five years later, Wehrle warned colleagues that the exact panels Arconic sold for use on Grenfell were “DANGEROUS on facades” and urged that “everything should be transferred to FR [fire-resistant] as a matter of urgency”. It didn’t happen.

Lawyers for the bereaved claimed that Arconic targeted sales of PE in countries such as the UK known to have more lax regulation. There was a commercial incentive to continue selling the combustible version: it was cheaper and more profitable than the fire-resistant alternative. Stephanie Barwise QC, counsel for bereaved and survivors, said: “Arconic knowingly and deliberately prioritised profits over safety.”

After his no-show was announced, Wehrle was doorstepped by reporters at his home in Alsace and insisted he would not be giving evidence following legal advice. “I don’t see what it can bring to those unfortunate people,” he said. “I did my job in my country and that’s it. I am really upset by this. It brings me great, great sadness.”

Millett and his team were able to reconstruct much of Arconic’s role from internal emails. One of the most staggering recorded an Arconic marketing manager telling colleagues about a 2007 seminar delivered in Oslo by a cladding expert. The expert had said that fires involving ACM PE cladding – and there were several before Grenfell, in Qatar, the UAE, Australia and France – produce huge clouds of toxic smoke that can kill within three minutes. The expert had even posited a scenario of 60-70 people killed by a fire fuelled by ACM PE panels – and asked: “What is the responsibility of the ACM supplier?” Shocked, the Arconic marketing manager said the business seemed so risky that it might be time to only sell fire-retardant panels.

At the inquiry, Arconic refused to take responsibility for what happened at Grenfell. It said the supply of the panels was lawful and it had taken steps to encourage the use of fire-retardant products before the disaster. Grenfell’s professional team ought to have known the risks of using the PE version with other combustible materials, it claimed. Arconic’s lawyers argued that it couldn’t guarantee the performance of its products once fabricated, and that it had no choice over the materials with which ACM was used. It also cited evidence that builders should have known it was “easily ignited and combustible”. Stephen Hockman QC, argued that “The tragic outcome of the Grenfell Tower fire resulted not from the use of ACM PE but from the way in which it was used,” adding that it would be “deeply unfair to try to pin the blame on the manufacturer”. It was a position that enraged the bereaved.

Yet if Kingspan, Celotex and Arconic provided the fuel, the spark would come from political choices made closer to Grenfell Tower – inside the smart offices of the Royal Borough of Kensington and Chelsea (RBKC) in the affluent south of the borough.

The council and the rebel residents: ‘We were treated as sub-citizens’

Rock Feilding-Mellen is the son of hippy aristocrats. His mother, Amanda Feilding, Countess of Wemyss and March, is best known for trepanning her own skull in 1970 in pursuit of altered states. Educated at Winchester and Oxford, and with a family stately home, his world was far from that of the Grenfell Tower residents. He became a councillor aged 27, and by 2013, aged 33, he was deputy leader with control of housing, property and regeneration in a borough containing some of the most expensive land in Britain. It gave him oversight of the Grenfell Tower refurbishment.

Many councils had seized on property development, some to fill holes left by government cuts, others out of free-market instinct and desire to boost home-ownership. A prime potential redevelopment zone in Kensington and Chelsea was Grenfell Tower and its surrounding 1970s estates. This had long been the genteel borough’s poorest area. In the 1930s the Labour MP Sir Stafford Cripps lamented: “Of all the slums in England, those in north Kensington are the most tragic.”

Inside the council, the tower was assessed as one of the borough’s “worst property assets” and “a poor cousin” that “blights” the surrounding area. From a purely financial perspective, the council viewed Grenfell as worthless. Laura Johnson, director of housing, wrote a memo to the effect that anything spent on Grenfell was money down the drain.

In 2009, a plan commissioned by the council had recommended demolishing Grenfell and replacing it with a mix of social and private housing, including more than 1,000 homes for sale. So in 2012, when the refurbishment scheme for Grenfell was proposed, Feilding-Mellen asked if it would “obstruct” the “bigger, longer-term potential”. Another councillor remarked that a proposed £6m refit might seem “a terribly nice thing to do” but it was wrong to divert money from elsewhere in the borough. (In 2013, Kensington and Chelsea had £241m in reserves.)

Rock Feilding-Mellen, former deputy leader of Kensington and Chelsea council.
Rock Feilding-Mellen, former deputy leader of Kensington and Chelsea council. Photograph: Richard Gardner/REX/Shutterstock

Despite being the council member for housing, Feilding-Mellen only recalled “skimming” London Fire Brigade documents that spelled out councils’ “legal duties to keep properties safe from fire”. He did, however, have strong feelings about the colour of the cladding. “The lime green should be less neon and a more pastel shade of green/turquoise or a deeper/darker British racing green,” he wrote to the Kensington and Chelsea Tenant Management Organisation.

The inquiry heard there had been deep antagonism between the council, the tenant management organisation and some of the residents, such as Ed Daffarn, who had lived on the 16th floor since 2001. He was one of a group that the landlord’s contractor branded “rebel residents”. Daffarn’s complaints included the quality of works, failure to involve residents in the choice of cladding and windows, and the low budget.

In November 2016, Daffarn predicted on the Grenfell Action Group blog: “Only an incident that results in serious loss of life” would expose “the malign governance of this non-functioning organisation”. The tenant management organisation blocked staff from accessing his blog on its work computers.

Daffarn wasn’t alone. Lee Chapman, 22nd-floor resident and secretary of the tower’s leaseholder association, told the tenant management organisation three months before the disaster that they were “seriously concerned” about the risk of fire. “As residents in a so-called ‘social housing block’, we were treated as sub-citizens,” he told the inquiry.

‘Flowing responsibility’: the uses of subcontracting

Within days of the fire, a handful of project documents from the tenant management organisation were leaked. They contained discussions about changing the cladding panels in order to cut costs. Switching from non-combustible zinc panels to ACM represented a saving of £293,368. Feilding-Mellen said in a statement to the first phase of the inquiry in October 2018 that he had been told the tenant management organisation was hoping to save money by switching the cladding, but said he didn’t know anything about the technical properties of the cladding options.

Kensington and Chelsea maintains it was reasonable to expect it was “entering a market that was sufficiently well regulated to ensure that there was minimal risk”. Instead, it found itself in “a world full of potential snares and pitfalls”. It also said it was obliged to seek good “value for money” when spending taxpayers’ funds.

Feilding-Mellen told the inquiry he supported the refurbishment, and said the council would have increased the budget “had we been told it was necessary to ensure residents’ safety”. He said he will “live with the memories of that early morning for the rest of my life”.

Millett’s team revealed numerous instances of money trumping safety. In tendering for the contract, the tenant management organisation had stretched public procurement rules in ways that “may have resulted in the selection of both an architect and a contractor ill-equipped to carry out the project,” lawyers for the bereaved alleged.

When the Grenfell refurbishment contract was tendered, three builders submitted bids. However, one firm, Rydon, was advised to find extra savings of £800,000. The tenant management organisation’s director of regeneration, Peter Maddison, had previously worked with some of the executives at Rydon and the tenant management organisation held an “offline” meeting with the firm to discuss potential savings.

Rydon won the contract but had underquoted for the job by more than £200,000. It then had to recoup its costs in other ways. Simon Lawrence, Rydon’s project manager, set out to persuade the planners that ACM PE was not an inferior product to the more expensive zinc. “I’m giving it my hardest sales pitch as we speak,” he emailed colleagues. “Come on the Essex-boy patter!”

On the occasions that doubts were raised about the contracts, they tended to be ignored. In September 2014, the tenant management organisation’s project manager, Claire Williams, emailed Lawrence requesting “clarification of the fire retardance of the new cladding”. There is no record that Lawrence answered her email. In the same year, the tenant management organisation’s legal department queried whether Rydon’s £9.2m bid was “abnormally low”. When quizzed about this by Millett, Peter Maddison replied: “The project was delivered on budget and that’s the best sign as to whether or not the price was the correct price.”

“Well, Mr Maddison,” responded Millett, “the fact that the project was delivered on budget is not of great assistance to us given that we know what happened to the building.”

Contractually, Rydon was “fully responsible in all respects for the design” but insisted the overwhelming responsibility for the loss of life lay with Arconic, Celotex and Kingspan the cladding manufacturers, who, it alleged, acted with “systematic deceit and dishonesty”.

Rydon was at the top of a chain of subcontracting that allowed it, in the words of one executive, to “flow … responsibilities” to others. For example, it subcontracted a facade company, Harley Facades, which in turn subcontracted another firm to do the work on site. Professionals repeatedly relied on others for assurances. Rydon subcontracted the job of making good the areas around the new windows with non-combustible mineral wool, but in the end, it was done with combustible foam instead. Simon O’Connor, a site manager, didn’t bother to check whether the subcontractor was proposing to use the right material. “It probably was my job, and no, I don’t recall doing it,” he said.

John Hoban, former senior building control surveyor at Kensington and Chelsea council.
John Hoban, former senior building control surveyor at Kensington and Chelsea council. Photograph: Grenfell Tower Inquiry/PA

The testimonies suggested carelessness and a reluctance to take responsibility, but also a lack of confidence on the part of people working in supply chains too complex for them to understand. A number of those questioned suggested that ultimately, companies relied on the council’s building control inspectors to ensure compliance. In the case of Grenfell this was John Hoban, who had seen his department at Kensington and Chelsea shredded by austerity. From 2013-2017 it had lost 10 experienced building inspectors and gained a single new graduate. At one point, Hoban had 130 projects to oversee.

He told the inquiry he trusted the designers and fire engineers on Grenfell, and admitted to not checking drawings and specifications properly, and not understanding the combustibility of materials.

“Are you saying because Grenfell had a team of experienced professionals, you were less ruthless and rigorous than you would have been had they not been there?” asked Millett.

Hoban denied he was “relying” on them, but said: “I can only do so much in a day, Mr Millett, and I have to prioritise my work, I have to make judgments.”

In tears, he said he was heartbroken for “the children, the brothers and sisters, sons and daughters, fathers, mothers, grandfathers, grandmothers” who died.

The government’s role and Cameron’s red-tape bonfire

In February 2022, the final phases of the inquiry began. After 237 days, it was finally time for ministers and Whitehall officials to take their place in the witness box. Many following the inquiry wondered if the government’s failure to simply ban ACM PE panels on tall buildings was ultimately to blame.

The inquiry heard about numerous warnings that had been missed or ignored. After a cladding fire at Garnock Court in Scotland in 1999 destroyed flats on nine floors and resulted in one man’s death, a House of Commons select committee concluded that cladding systems should either be entirely non-combustible or justified through full-scale tests. The recommendations were ignored. Shortly afterwards, a government survey of high-rise cladding elicited a warning from construction firm WS Atkins about the risk of flame spread, but nobody in government followed up.

But perhaps the most shocking revelation concerned the government’s response to a fire at Lakanal House in Southwark in 2009 that had killed six people. In 2013, the coroner for the inquest, Frances Kirkham, complained that the building regulations guidance to constructors about fire safety was a “most difficult document to use”. It failed to answer straightforward questions about what materials were allowed and needed to be reviewed. The communities secretary, Eric Pickles, promised a new version by 2016-17, but it never came. Millett wanted to know why.

At the time, David Cameron’s coalition government had embarked on a “red tape challenge” – a drive to cut business costs to help an economy still limping out of the financial crash. “All those unnecessary rules that place ridiculous burdens on our businesses and on society − they must go, once and for all,” Cameron told ministers in April 2011. By January 2012 he wanted to “kill off the health and safety culture for good”.

Eric Pickles at the inquiry in April this year.
Eric Pickles at the inquiry in April this year. Photograph: YouTube

“We found ourselves spending an inordinate amount of time looking at how we could deregulate,” Anthony Burd, an official tasked with securing building safety in Pickles’ department, told the inquiry. Brian Martin, who had been the civil servant in charge of official building regulations guidance, told Millett: “Ministers were very focused on avoiding anything that might impact on the economy in a negative way.”

Pickles was the most senior of five ministers to appear before Moore-Bick and Millett, on day 261 of the inquiry. He did not endear himself to those watching, complaining to Moore-Bick that if the questions went on much longer he might have to cancel the “international guests coming in to see me”, and telling Millett that “I urge you to use your time wisely”.

Pickles insisted he had accepted the Lakanal coroner’s recommendations, but his letter to the coroner in May 2013 pushed back against her call for a review of regulations. It said: “my department is committed to a programme of simplification. However, the design of fire protection in buildings is a complex subject and should remain, to some extent, in the realm of professionals.”

After Pickles stood down in May 2015, the Conservative peer James Wharton was appointed as a junior minister with responsibility for building regulations. In September of that year, Conservative MP David Amess warned Wharton that there were problems with the government’s fire safety regulations that had “life safety implications” that needed to be dealt with “immediately”. Wharton agreed to meet Amess, but when they met, he told him that his principal objective was reducing red tape.

There was plenty of evidence that civil servants and politicians knew the risks. The inquiry saw how, in April 2015, Brian Martin had written a “worry list” that included the need to review the fire safety guidance. Under the heading “what happens if we don’t act?” he had written: “Bigger building fires!” After a dramatic ACM PE cladding fire in Dubai in January 2016, Martin emailed colleagues commenting it makes “nice shiny buildings” but “when it gets exposed to a fire, the aluminium melts away and exposes the polyethylene core. Whoosh!”

The ministers and civil servants questioned by Millett were often combative, contradictory and vague. However, there was one moment that stood out among the hours of evasion. When Millett asked Martin, “Is there anything you would have done differently?”, the civil servant was visibly distressed. “I find it difficult to express how sorry I am for what’s happened to the people of Grenfell Tower,” he said, his voice cracking. “There were a number of occasions where I could have potentially prevented this happening.”

Supply chains and the violence of distance

Moore-Bick’s final report, expected next year, is likely to nominate multiple wrongdoers. After that, the police may pursue criminal charges, including corporate manslaughter. But the significance of the inquiry goes beyond this. It has exposed, in almost unfathomable detail, many of the most dangerous tendencies that underpin contemporary society. There was David Cameron’s crusade against red tape, as if regulation exists only to impede business; a council that couldn’t decide if it was a housing provider or a property developer; and a wider mania for subcontracting that doesn’t so much devolve responsibility as evaporate it.

Watching the inquiry unfold, I was struck by two troubling side-effects of the ever-increasing complexity of modern supply chains. At Grenfell, the endless subcontracting gave executives a false sense of security that others would make up for their shortcomings in effort and expertise. Meanwhile, the proliferation of organisations involved in even a relatively straightforward building project seemed to leave workers feeling powerless to act against wrongdoing.

Perhaps most disturbing of all was that the question of wrongdoing did not even seem to occur to many of the people working in those complex supply chains. Time and again, witnesses seemed nonplussed when asked to consider their responsibilities or confronted with the results of their actions. Most saw themselves as just one part of a long chain, who couldn’t be expected to see the whole picture, never mind bear responsibility for it.

The sociologist Zygmunt Bauman once wrote that violence in our age is defined by distance. Summarising Bauman’s idea, the journalist Daniel Trilling has written that this means not only physical distance, “but the social and psychological distance produced by complex systems in which it seems everybody and nobody is complicit. This, for Bauman, works on three levels. First, actions are carried out by “a long chain of performers”, in which people are both givers and takers of orders. Second, everybody involved has a specific, focused job to perform. And third, the people affected hardly ever appear fully human to those within the system. “Modernity did not make people more cruel,” Bauman wrote, “it only invented a way in which cruel things could be done by non-cruel people.’”

This was not the whole story of the inquiry. Such heedlessness does not apply to all of those whose actions were under scrutiny. Some individuals seemed to bear greater direct responsibility. But Bauman’s theory may explain why so many people knew the dangers and still did nothing to prevent disaster – and why, until we change the way our society is organised, it might happen again.

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