GRENFELL FIRE

GRENFELL FIRE Why were so many failed?

About 80 people lost ix weeks ago, we lived in a more person. Unlike in previous national disasters, innocent time. It was possible to such as Hillsborough, in 2017 the voices of their lives in the smoke believe in a robust system of regula- the Grenfell residents and survivors are likely tion and enforcement that was driv- to be heard loud and clear throughout the and flames of Grenfell Sing fi re risk down, that residents of high-rise inquiry. So it’s through their eyes that we have Tower. The disaster blocks were no less safe than those of us who to look at Building Regulations, in particu- live closer to the ground, and that the con- lar the fi re safety requirements in Approved has exposed shocking struction sector and building control failures, and shocking inspectors were working to standards that protected public safety. But that There was a systemic complacency. Elaine was the past, and now we live in a world where regulation, enforcement breakdown in fire safety Knutt looks at the and accountability failed at least 80 residents of who were regulation and governance. regulations that should killed in horrifi c circumstances. Decisions are disjointed ... As the Grenfell Tower inquiry gets have kept people safe underway, Health and Safety at Work with not enough regard for has asked architects, fi re sector repre- fire safety” sentatives, construction experts and lawyers for their view on what contrib- Celestine Cheong, Fire Protection Association uted to the disaster. And while no one wants to pre-judge criminal and civil proceedings, or make assumptions on what Document B (AD B); and the system of fi re went wrong, it’s right to bring that scrutiny risk assessments brought in by the Regulatory to bear: it’s been argued that lack of media Reform (Fire Safety) Order. interest was one reason why known regula- Thomas Roche, chair of the built environ- tory weaknesses and fi re risks persisted. ment workstream at the Fire Sector Federa- One theme that emerges is that regula- tion, which aims to shape policy on fi re safety, tion around fi re safety was too disconnected, says there were “gaps” in accountability. “Do ambiguous and impenetrable for the lay we have the right priority on fi re and the right

18 August 2017 | healthandsafetyatwork.com 23 GRENFELL FIRE Marco Gott ardi Gloria Trevisan 22 Raymond Bernard Zainab Choucair Fathia Hasan Mierna Choucair Hania Hasan Fati ma Choucair Rania Ibrahim Bassam Choucair Hesham Rahman Nadia Choucair Mohamed Neda Sirria Choucair Fathia Alsanousi Firdaws Hashim Abufars Ibrahim Yaqub Hashim Esra Ibrahim Yahya Hashim Hashim Kedir Nura Jamal Ligaya Moore 21 Anthony Disson Mehdi El-Wahabi Mariem Elgwahry Nur Huda El-Wahabi Yasin El-Wahabi 20 Fouzia El-Wahabi Mary Ajaoi Augustus Mendy Abdul Aziz El-Wahabi Khadija Saye Malak Belkadi 19 Leena Belkadi Deborah Lamprell Farah Hamdan Ernie Vital Omar Belkadi Marjorie Vital Jessica Urbano Ramirez Mohamednur Tuccu Amaya Tuccu 16 Amal Ahmedin Sheila Smith 18 15 Fati ma Afrasehabi Steven Power Sakineh Afrasehabi Isaac Paulos Hamid Kani Biruk Haft om 17 f-caption f-caption f-caption f-caption Vincent Chiejina 14 Brkite Haft om Mohammed Abdul Hanif Mohammed Abdul Hamid Denis Murphy Husna Begum Mohammed Alhajali Rebeya Begum Jeremiah Deen Kamru Miah Zainab Deen Khadija Khalloufi 11 Abdeslam Sebbar Ali Yawar Jafari

+ GRENFELL’S VICTIMS Out of 350 people who were supposed to be in Grenfell Tower on 14 June, the Met- ropolitan Police confi rmed on 10 July that 255 people survived, 14 were elsewhere at the ti me, and around 80 lost their lives. The BBC has compiled informati on about the victi ms of the fi re, naming 64 of the 80 individuals who died. Their names appear above. Thirty-two victi ms have been identi fi ed by the coroner: their names are in bold, although not all 32 have been named. The informati on above is accurate as of 13 July.

healthandsafetyatwork.com | August 2017 19 STRAP

GRENFELL FIRE

controls in place to insist on that priority? contributed to the Grenfell disaster. But the explained that it expected the inner fi lling Have we got a consolidated approach across weeks following the fi re have seen a consist- inside the Aluminium Composite Material the government and the sector? We’ve created ent focus on the materials used in the tower’s (ACM) “rainscreen” cladding panels to meet gaps: not intentionally, but just by the nature £8.7m refurbishment, following shocking a “limited combustibility” standard. But of the complexity of the building process. The video evidence of a strip of fl ame reaching up many construction teams – and presumably sticking plaster solution would be clearer the corner of the building by 1.30 am on 14 building control inspectors too – relied on an guidance on material specifi cation, but that June. The investigations might conclude that interpretation of AD B that suggested that a wouldn’t fi x the overall issues.” the fi re also spread within poorly-compart- building’s external surface at heights over At the Fire Protection Association, which mentalised fl oors, or in risers. But it seems 18m simply had be “Class 0” for the spread had pressed the government to implement obvious the blaze would not have been so and propagation of fi re. In the DCLG’s inter- the recommendations of the Lakanal House deadly if the building had not been reclad. pretation, the Class 0 “external surface” was coroner on re-writing AD B for clarity, spokes- The immediate questions on the Gren- the external face of the panel; others thought person Celestine Cheong says that Grenfell fell refurbishment, which reportedly had it referred to the entire panel as a whole. highlights a “broken system”. “There was a 16 building control inspections from the As many have highlighted, AD B is very systemic breakdown in fire safety regula- council, soon widened into a national issue. A complex, off ering multiple alternative routes tion and governance. Decisions about design government testing programme found that at to compliance, and zig-zag references to strategies, products, techniques, certifi cation, least 190 other high-rises featured rainscreen appendices, tables and other guidance: hous- competency and auditing are made in a dis- cladding that failed its combustibility test. If ing architect Julia Park, writing in Building jointed and often ineff ective and inconsistent the Grenfell refurb team, led by contractor Design, calculated that AD B makes reference manner, with less regard for fi re safety than Rydon, had misinterpreted the Regulations, to no fewer than 93 other documents. should be the case.” then so had hundreds of others across 51 local Rudi Klein, a barrister and chief executive authorities. of the Specialist Engineering Contractors’ National cladding crisis The explanation is found in AD B, which Group, says: “[Building Regulations] are not It seems clear that multiple failures – from has not been comprehensively revised since drafted in a prescriptive way, they don’t say the council’s “value engineering” to opera- 2006. On 2 July, the Department for Com- ‘you shall’, they’re drafted in terms of out- tional issues at Fire Brigade – all munities and Local Government (DCLG) comes. They need to be easily understood by

+ CLADDING FIRE TIMELINE Abdallah Adel/NurPhoto/REX/Shutt erstock Adel/NurPhoto/REX/Shutt Abdallah Ben Curti s/PA Archive/PA Images Archive/PA s/PA Curti Ben Xinhua News Agency/REX/Shutt erstock Agency/REX/Shutt News Xinhua Wooden Pegg/YouTube Wooden

JUNE 1999 MAY 2012 NOVEMBER 2014 FEBRUARY 2015 DECEMBER 2015 Garnock Court, Irvine Mermoz Tower, France Lacrosse, Melbourne Marina Torch, Dubai The Address, Dubai The flats had been given The Roubai x tower had More than 400 people A fire started on the Fire engulfed the 63 sto- new of floor-to-ceiling been refurbished and were evacuated when 51st floor of the 86 rey hotel on New Year’s unplasticised polyvinyl reclad nine years before a fire that started on storey tower, thought Eve, the third major chloride (uPVC) window the fire killed one person an eighth floor balcony to have been started blaze in Dubai after the units. When a fire started and injured six. The spread vertically to the by a cigarette or shisha Tamweel in 2012 and on the fifth floor, a vertical refurbishment included roof within 10 to 15 coal left on a balcony. the Marina Torch in ribbon blazed. A 55-year- adding metal compos- minutes. The build- Eyewitness video shows 2015. Sixteen people old man died. A House of ite cladding above the ing was clad in 4mm large quantities of burn- suffered minor injuries. Commons Select com- ground floor: the panels aluminium composite ing material falling from The cladding on The mittee report questioned had a 3mm polyethyl- material (ACM) panels a high-level fire starting Address was described the fire tests under AD ene core sandwiched with a polyethylene a secondary fire at a by supplier Alumco as B at the time. In 2000, between two 0.5mm core, from Alucobest. lower level. The Marina an ACM with a poly- the Regulations were aluminium sheets. Investigations found that was among the 70% of ethylene core material. changed, introducing the According to one they had not been tested the high-rise develop- Similar products were BS 8414 test. But other researcher, residents in accordance with ments in Dubai clad with used routinely in Dubai’s compliance routes and were concerned about the relevant Australian aluminium composite building boom, but were ambiguities remained. the quality of the refit. standards. material panels. outlawed in 2013.

20 August 2017 | healthandsafetyatwork.com GRENFELL FIRE

the people who put them in place and operate them. People know there isn’t much enforce- A WARNING IGNORED ment [from building control inspectors], and + that creates a certain culture.” The parallels between Grenfell Tower and the For Roche, the question of how the Gren- Lakanal House fire in Southwark in July 2009 are fell team and the wider construction industry clear. At Lakanal House, where six people died, interpreted AD B will be at the “core” of the the inquest established that a principle cause public inquiry. “What is Approved Document of the fire’s rapid spread – trapping the victims B and how does it fit? Is it law, or is it guid- in two flats – was the inadequate fire resistance ance? Then there is other guidance [from of the recently replaced exterior panels. Flames industry and manufacturers] and other routes leapt from one flat to another within 15 minutes, to compliance. When you work to functional confounding London Fire Brigade’s “stay put” requirements, it opens the door to other policy and rescue attempts. routes,” he says. “The doubts at the heart of A construction project team (Southwark Building this are the reason we’re calling for a review Design Services as project manager and Apollo as to find an answer to relatively straightforward

[of AD B]. We need clarity, and on the wider contractor) had taken a building with moderately Image: REX/Shutterstock questions”. Kirkham suggested that AD B should issue of enforcement and competency, too.” good exterior fire resistance – the original panels be reviewed to be “intelligible to the wide range But such a widespread and safety critical contained asbestos – and weakened it. of people and bodies engaged in construction, misinterpretation of AD B suggests that the But one reason why the Lakanal case did maintenance and refurbishment”, and also rec- DCLG and its advisers – the Building Research not resonate more strongly was that the panels ommended that AD B should provide guidance Establishment has a contract to provide fire were established to be non-compliant with AD to assist those involved in the maintenance or advice to it, and a panel of industry experts B. Therefore, the coroner’s conclusion was that refurbishment of older housing. sit on the Building Regulations Advisory Com- AD B itself was not at fault, rather there were The coroner also pointed out that retro-fitting mittee – were, at the very least, detached from problems with its compliance and enforcement. sprinkler systems in high rise residential buildings what was actually happening in hundreds of On the other hand, the inquest demonstrated “might now be possible at lower cost than had construction projects across the country. just how confusing and open to interpretation AD B previously been thought to be the case, and with This ambiguity clearly demonstrates the could be, with one expert witness giving evidence modest disruption to residents”. urgent need to re-write AD B to improve clar- that the panels should have 60 minutes’ fire resist- David Gold, chair of the IOSH fire risk man- ity and meaning – a recommendation of the ance, only for the Department for Communities agement group, says that international statistics coroner in the Lakanal House inquest in 2013. and Local Government to clarify that this was not show that following fires where sprinklers are It took the DCLG two years and pressure from the case. When Judge Frances Kirkham sent her involved, deaths, injuries and property losses the Construction Industry Council and Fire Rule 43 letter to then communities secretary Eric are all significantly lower. “The sprinkler is one Sector Federation to accept that recommen- Pickles, she therefore concentrated on the fact of the most effective tools we have. It’s far dation, a further year to commission a survey that AD B was so impenetrable. She described more effective than putting an extinguisher in (by RIBA offshoot NBS) and another year to it as a “most difficult document to use in order someone’s hands,” he says. release a report based on the survey results. It was published a week after the Grenfell fire. One result of AD B’s complexity, according dence on multiple fires around the world linked The statistics created false comfort, to Hugh Robertson, health and safety policy to polyethylene rainscreen cladding. “We were argues Roche. “Is Grenfell an anomaly, or officer at the TUC, is that it’s impossible for told we would see the review in 2016–17, but an indication of an underlying trend that we non-professionals to see whether or not the the government hadn’t yet gone out to consul- need to take heed of? Many would say that building they live or work in complies with tation, and it takes at least 18 or 24 months of just because we haven’t seen an event like this statutory requirements. “It puts fire safety in consultation to do it properly,” notes Roche. before, we need to ask what this is telling us the hands of the ‘experts’. The people who live The RIBA is now calling for a “comprehensive, about the built environment.” transparent and funda- Fire risk assessors point to a lack of cohe- mental reappraisal [of AD sion between FRAs and construction checks, It puts fire safety in the hands of B], rather than amend- with gaps in enforcement. “I see building ‘experts’. The people who live or ment or clarification, to control failures all the time, things that an ... provide clarity and inspection should have picked up,” says Wil- work in high rise blocks should have protect public safety”. liams. “There’s so much work done by sub- a simple answer on whether their contractors, and who’s checking that the work Risk and reward has been done correctly? We find doors miss- buildings are safe” The other side of the ing their hinges; door frame casings missing; Grenfell’s failed safety intumescent seals missing.” Hugh Robertson, TUC net is fire safety regu- And that’s the work the fire risk assessors lation. In 2005, the can see, and not the roof spaces or service Regulatory Reform Fire areas that the assessors either wouldn’t see, or work in high-rise blocks should be able to Safety Order (RRFSO) brought the regime be qualified to make a judgement on, or have have a simple answer to whether their work- of fire risk assessments (FRAs), enforced by leverage over. “If I’m in a corridor with a false place or home is safe. If a building is being spot-check audits by fire and rescue services. ceiling, I’ll lift up the panels, but I won’t climb refurbished, the safety reps should be able to Once, the reforms seemed statistically proven in all of the ducting – that’s not the role of a check it’s safe. The way the regulatory system to be a success: Home Office figures suggest fire risk assessor,” says Jonathan Backhouse, works, so much is based on standards which that although the number of audits was in who explains that he follows the methodology are not accessible,” he says. decline, the number of fires was too (see p22). laid out in PAS 7. In that situation, he says, he While the DCLG had made limited progress “The recent cuts to the fire and rescue services would recommend an additional study. But on clarifying AD B, it had also failed to deliver were predicated on things becoming safer,” there is no legal mechanism to enforce the cli- on a promise of a wider-ranging review, a pro- says health and safety consultant Ashley ent to undertake such a study, far less act on it. cess that would most likely have taken in evi- Williams, who often carries out FRAs. Many commentators compare the healthandsafetyatwork.com | August 2017 21 STRAP

GRENFELL FIRE

enforcement gaps in the current regime Works, a road map for construction INSPECTIONS AND FIRES to the higher levels of enforcement pre- + projects. The individual certifying that

2005. “In the cases of a FRA, you just 90,000 Dwelling fires the works were in accordance with all have it done, keep it and comply with 80,000 Non-dwelling fires fire safety considerations would incur the recommendations. In the past, the legal liability if things went wrong. 70,000 Audits fire and rescue services inspected all And if the technical or material speci- 60,000 properties and issued a fire certificate fications were later changed – as in the which stated ... what precautions a com- 50,000 kind of “value engineering” exercise pany or organisation had to take,” says 40,000 that apparently happened at Grenfell – Cheong at the FPA. 30,000 then further sign-off would be needed. Post-Grenfell, other shocking fail- 20,000 The first draft of its “Construction ures in the fire safety integrity of social 10,000 Strategy” was due to be launched at housing have come to light. At Cam- 0 Firex, but was postponed. The ASFP’s den’s Chalcots Estate, a “thousand” fire 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 Rowan says it is now seeking as wide doors were either missing or ineffective, a group of stakeholders as possible an issue that believes regulation is split between government depart- to participate in drafting a workable came to light in 2012 but was not acted upon; ments: the fire service and the RRFSO is under strategy for the industry. in Southwark’s Ledbury Estate in Peckham, the Home Office; Building Regulations are engineers were only sent to check serious under the DCLG; schools are under the Depart- The new realities structural cracking that comprised fire com- ment for Education; and the NHS falls under As everyone involved in health and safety partmentation after the residents demanded the Department of Health. “How do we join all adjusts to the new realities post-Grenfell, action after the Grenfell fire. these up within government?” he asks. where faith in our regulatory system no longer The TUC’s Robertson says there had been Industry bodies had attempted to step in seems quite so well-founded, opinion is split a rising sense of complacency around fire where government had failed to act: Roche’s between calls for more regulation, or simply safety. “Overall, fire safety has become less of Built Environment Affairs and Issues work- far better enforcement and monitoring of the a priority for everyone. The Fire Safety Order/ stream had been “working on issues around regulations we already have. At the TUC, for fire risk assessment system only works if the wording of AD B, such as have we got the instance, Hugh Robertson says it’s too soon to there’s an inspection support system, but risk definitions right?”. Its interim report was due judge whether the RRFSO system is still fit for assessments aren’t always checked.” David to be launched on June 15 at Firex. “It was purpose, or if the failings lie elsewhere. Gold, chair of IOSH’s fire risk management part of a strategy to say we need to push gov- Rudi Klein, however, calls for a re-think group, says that it cautioned the All Party ernment for the review of Part B because it’s on Building Regulations. “Because of pressure Parliamentary Fire Safety and Rescue Group taking too long,” says Roche. on local authority resources, there’s a general (APPFSRG) of a risk of complacency in 2016. At the FPA, Cheong was involved in pro- lack of enforcement of regulations and stand- Williams argues that a lack of transpar- ducing guidance that was never released, ards. The bulk of the Regulations are aimed ency and statistical data is fuelling the lack of at public safety, wel- accountability. “The prosecutions [by regional fare and wellbeing, so fire services] are hidden on the website of the Any call for change gets a question why not have a national Chief Fire Officers’ Association; and what’s enforcement regime?” there isn’t in-depth,” he says, comparing the back, which is ‘show me the Rowan identified the situation to the relative openness of the HSE’s evidence’. We hadn’t seen action, but pressures faced by build- prosecution database and press releases. “Fire ing control departments, safety is a difficult area at the end of the day, no one was saying no” shrinking due to auster- and lack of transparency doesn’t help.” Thomas Roche, Fire Sector Federation ity measures while sub- ject to competition from Evidence-based decisions private sector approved It’s now clear that various branches of cen- inspectors. The GMB, tral and local government received direct which may have addressed some of the issues meanwhile, has revived a debate on licensing warnings that fire safety standards in the UK raised by fire risk assessors. “There was new construction contractors to raise public safety. were at risk: the APPFSRG, the Fire Sector Building Control and Fire Safety Procedural Cheong calls for more research, and more Federation, the Fire Protection Association, Guidance produced over two years ago, reviews of the regulation we rely on. “Keeping insurers bodies and the London Fire Brigade overseen by the Fire Sector Federation and pace with technical developments and learn- all sounded the alarm at various times. But checked by DCLG’s legal team and placed in ing from real events is essential in the fire sec- why did none of these attempts – singly or in line for publication. However, we have not tor, it’s the regulatory framework that hasn’t combination – trigger a government response? seen this accomplished to date.” kept up.” Roche is also looking to the future. The Fire Sector Federation’s Roche tries to At the Association for Specialist Fire Pro- “If we build combustible buildings today, we explain. “I wouldn’t say that it was like howl- tection (ASFP), chief operations officer Niall have to live with them for 30 years unless ing at the moon. People listened. But what we Rowan says that building projects are often we’re prepared to rip things apart. The sta- recognise about government is that we need to inadequately inspected for fire safety, in tistics might not change for years if we build give evidence: any call for change gets a ques- part due to the number of firms, including buildings at risk today.” tion back, which is ‘show me the evidence’. We third party assessors, involved in a project. What seems certain, however, is that the hadn’t seen action from government, but on “Building control sometimes inspect for fire post-Grenfell world will need a new ap proach the other hand no one was saying no.” safety and sometimes they don’t. There are to fire safety, which recognises that existing And gathering the necessary “evidence” many situations where the fire stopping is not regulations were both too complex and not would not have been easy: there is no chan- inspected, and contractors know that.” sufficiently updated; that there were gaps in nel to filter the experience of building control A year ago, the ASFP decided it had seen accountability; and that enforcement either departments to government, or to aggre- enough evidence of poor enforcement to take wasn’t comprehensive or acting as a sufficient gate the findings of fire risk assessments. action. It was working on the introduction of deterrent. And above all, that getting these Another complication, Roche adds, is that fire a new “sign off” stage in the RIBA’s Plan of issues right is what keeps people alive. n

22 August 2017 | healthandsafetyatwork.com