A web of blame: key findings from the second phase of the Grenfell inquiry

A web of blame spanning from corporate headquarters in the US and France to elected chambers in Kensington and Westminster is due to be exposed next week, when the Grenfell Tower public inquiry delivers the first official verdict.

In the more than seven years since an entire community was traumatised, survivors and bereaved people have been clamouring for transparency and accountability. The report, distilled from 400 days of evidence and more than 300,000 documents, will finally be ready for public release on Wednesday – and offers the best chance yet.

It will provide precise findings relating to allegations of incompetence, dishonesty, malpractice and indifference and is expected to draw damning conclusions about the acts and omissions of a multitude of parties who were responsible for the disastrous refurbishment that led to the worst residential fire in UK peacetime history.

There will be no Poirot moment when a single guilty party is exposed. The Grenfell Tower disaster is a system failure as well as a human one. About 250 people have already been warned they may be subject to criticism – likely to include former government ministers, council leaders and corporate executives.

The report will be closely studied by the thousands of people around Britain who have been caught up in the wider cladding scandal that has left them afraid for their safety and facing huge remediation bills.

Only last week a fire at an east London block of flats that had known fire-safety defects led the Grenfell United families group to warn of “the painfully slow progress of remediation across the country, and a lack of urgency for building safety as a whole”.

This will be the second report issued by the inquiry. The first, tackling the night of the fire and the response of the emergency services, was released in October 2019 and identified the London fire brigade’s “gravely inadequate preparation and planning”. It concluded that lives were lost owing to delays in abandoning the strategy of telling residents to “stay put” when it was clear the fire was out of control.

The inquiry is also undertaking the duties of a coroner and so Sir Martin Moore-Bick’s report will detail the final painful hours of the residents of the tower who vainly sought safety and died trapped. They include 12-year-old Jessica Urbano Ramirez , from flat 176 on the 20th floor, whose mother and sister were out when the fire began. She was among many who died sheltering in the top-floor flat of Raymond “Moses” Bernard .

On the same floor, Rania Ibrahim and her infant daughters died along with Gary Maunders, Fathia Ali Ahmed Elsanousi, a retired school teacher, and her adult daughter, Isra Ibrahim. Elsanousi’s adult son, Abufras Mohamed Ibrahim, fell from the tower, hitting the entrance canopy. Hesham Rahman, 57, was among 15 disabled residents who died. Gloria Trevisan, 26, an Italian architect, called her mother and said: “I can’t believe its ending like this.” She died with her partner, Marco Gottardi.

When this second phase of the inquiry opened, Richard Millett KC said the statements made by the various parties involved in the refurbishment amounted to “a merry-go-round of buck passing”. But the inquiry revealed a mountain of evidence. Here we summarise some of the key discoveries.

The multinationals

A French subsidiary of Arconic, a US industrial giant, sold the highly combustible cladding panels that were the main cause of fire spread. It did so despite evidence showing the company knew two years before the disaster that they were dangerous.

In 2010, Claude Wehrle, head of technical sales support, told a sales colleague that the aluminium composite material (ACM) panels were combustible when formed into a cassette, as they were at Grenfell. He added: “we have to keep [this] VERY CONFIDENTIAL!!!!”

That was not the first warning. In 2007 Arconic’s marketing manager, Gerard Sonntag, reported to colleagues about a cladding expert who warned fires involving the type of cladding later supplied for Grenfell produced huge clouds of toxic smoke that could kill within three minutes. The expert asked: “What will happen if only one building made out PE [combustible polyethylene] core is in [sic] fire and will kill 60 to 70 persons?” Sonntag suggested the company should weigh up the financial consequence of selling only a fire-retardant version instead. No such decision was made.

Then there are Celotex and Kingspan – the firms that made the combustible phenolic foam insulation that released poisonous hydrogen cyanide gas when it burned. They were both accused of misleading the market in the way they used the byzantine system of testing, certification and regulation for building materials. Celotex was found to have cheated a fire test of its material by concealing sheets of fire-retardant board in the test rig.

Related: Celotex executive wrote ‘WTF?’ on fire test report, Grenfell inquiry hears

This happened despite the test being overseen by a supposedly independent organisation, the Building Research Establishment. The former government laboratory was privatised in 1997 and was paid tens of thousands of pounds by material manufacturers to test their wares. Sir Martin will weigh up if this supposed safeguard against corporate malfeasance was complicit or, as lawyers for BRE argued , responsible only for “shortcomings” and “naivety”.

Kingspan, which made only 5% of the insulation, was also accused by Millett of “malpractice … in the development and testing, promotion and sale” of its foam product and “misleading the market about the safety and compliance” of the material for tall buildings. It admitted to “process shortcomings” but said none were causative of the fire.

In 2008, when clients questioned the firm about the safety of the material on specific buildings, Philip Heath, a Kingspan technical manager, told colleagues the client could “go fuck themselves” and that builders asking questions were “getting me confused with someone who gives a damn”. On another occasion, in 2016, two members of the Kingspan technical team had an online conversation which began with the banter-ish salutation: “Maaaaaate”. They chatted about the company’s apparently misleading claims about the fire performance of its foam panels.

“All we do is lie in here,” concluded one , to which the other simply replied: “Aye”.

Kingspan said the inquiry had revealed some correspondence “containing wholly unacceptable sentiments about fire safety that in no way reflect our culture”.

The council landlord

The Royal Borough of Kensington and Chelsea was the wealthy Conservative-controlled borough that viewed Grenfell as a “poor cousin” that “blights” the surrounding area. In 2009 it had a plan to demolish the council block and replace it with a mix of social and private housing. So there was concern over the value of investing heavily in the building.

Related: Causes of Grenfell fire were entwined with policy decisions driven by saving money

When it decided to reclad the tower, one perceived benefit was that it would improve the appearance of the area. Rock Feilding-Mellen, the deputy leader of the council, recalled only “skimming” London fire brigade documents that spelled out councils’ “legal duties to keep properties safe from fire”. But he did express firm opinions about the colour scheme, writing that “the lime green should be less neon and a more pastel shade of green/turquoise or a deeper/darker British racing green”.

The council had hundreds of millions of pounds in reserves but its building control department was under-resourced and it “failed to carry out any proper investigation or inspection and should never have issued the completion certificate”, the inquiry heard.

Its tenant management organisation was accused by one leaseholder of treating residents as “sub-citizens”. Relations with tenants could be antagonistic, to the extent tenants organised to challenge and scrutinise its actions. Ed Daffarn, a resident, raised seven complaints relating to fire safety before the fire, and in November 2016 predicted on the Grenfell Action Group blog that “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.

In 2014, the TMO shaved a few hundred thousand pounds from the cladding budget by switching from a zinc product that was expected to be fire-retardant. The council also chose to spread a £620,000 bill for fitting door closers on all its council flats over five years instead of 12 months. On the night of the fire, many doors at Grenfell stood open, allowing deadly smoke to spread.

The UK government

Ministers were warned in 2013 that the fire safety regulations needed an overhaul. After six people died in a 2009 cladding fire at Lakanal House, another London council block, a coroner called for a nationwide review of the rules to make them more intelligible. She also wanted clear guidance on when “attention should be paid to whether proposed work might reduce existing fire protection”. The then communities secretary, Eric Pickles, did promise a new version of the building regulations by 2016-17, but it never came.

At the time the government was engaged in a “bonfire of red tape”. David Cameron’s Conservative government wanted to cut regulations to boost business after the global financial crisis. In 2012 Cameron said he wanted to “kill off the health and safety culture for good”.

Brian Martin, who had been the civil servant in charge of official building regulations guidance, told the inquiry: “Ministers were very focused on avoiding anything that might impact on the economy in a negative way.”

The inquiry looked into Martin’s inaction over the known risks of ACM cladding. In January 2016, when there was a fire in an ACM-clad tower in Dubai, he wrote: “When it gets exposed to a fire, the aluminium melts away and exposes the polyethylene core. Whoosh.” A couple of weeks later, a cladding supplier emailed him to express “grave concern” about the proliferation of ACM panels in the UK and urged a “less ambiguous statement of the rules”. It never came.

Architects and builders

The architect Studio E, the main contractor Rydon, the specialist contractor Harley Facades and the fire consultant Exova are among the building and design firms braced for criticism.

Related: ‘Life-critical’ fire issues found in 56% of Grenfell cladder’s residential blocks

A senior Rydon manager admitted in an internal email they were using “cheap incompetent sub-contractors” and complained about “massive pressure from the rebel residents about our quality of work”. Dangerous faults included the installation of combustible window surrounds, in breach of the specification.

Many of the submissions from this cluster of protagonists exemplify the buck-passing that Millett warned of. Moore-Bick is likely to grapple with the culture and consequences of sub-contracting risk and “flowing responsibility” to others, which was a leitmotif of the Grenfell story.

The fire brigade

The readiness of the London fire brigade to tackle a huge cladding fire is likely to be criticised. Parts of the LFB had a growing concern that stay-put policies might not work on many buildings because they were built in a way that would allow fires to spread. But this concern was not shared with frontline crews or translated into training. Such flexibility was held back by a “conservative and quite fearful workplace culture”. Despite a series of cladding fires in the UK and abroad, commanders and fire crews were not trained in how to respond.

Andy Roe, the current commissioner, who replaced Dany Cotton, who was in charge at the time of the disaster, told the inquiry the LFB was part of “the most appalling example of institutional failure … in recent British history”.