Why were so many failed?

Six weeks ago, we lived in a more innocent time. It was possible to believe in a robust system of regula-tion and enforcement that was driv-

ing fi re risk down, that residents of high-rise blocks were no less safe than those of us who live closer to the ground, and that the con-struction sector and building control inspectors were working to standards that protected public safety. But that was the past, and now we live in a world where regulation, enforcement and accountability failed at least 80 residents of Grenfell Tower who were killed in horrifi c circumstances.

As the Grenfell Tower inquiry gets underway, Health and Safety at Work has asked architects, fi re sector repre-sentatives, construction experts and lawyers for their view on what contrib-uted to the disaster. And while no one wants to pre-judge criminal and civil proceedings, or make assumptions on what went wrong, it’s right to bring that scrutiny to bear: it’s been argued that lack of media interest was one reason why known regula-tory weaknesses and fi re risks persisted.

One theme that emerges is that regula-tion around fi re safety was too disconnected, ambiguous and impenetrable for the lay

person. Unlike in previous national disasters, such as Hillsborough, in 2017 the voices of the Grenfell residents and survivors are likely to be heard loud and clear throughout the inquiry. So it’s through their eyes that we have to look at Building Regulations, in particu-lar the fi re safety requirements in Approved

Document B (AD B); and the system of fi re risk assessments brought in by the Regulatory Reform (Fire Safety) Order.

Thomas Roche, chair of the built environ-ment workstream at the Fire Sector Federa-tion, which aims to shape policy on fi re safety, says there were “gaps” in accountability. “Do we have the right priority on fi re and the right

About 80 people lost their lives in the smoke and flames of Grenfell

Tower. The disaster has exposed shocking failures, and shocking

complacency. Elaine Knutt looks at the

regulations that should have kept people safe

There was a systemic breakdown in fire safety regulation and governance. Decisions are disjointed ... with not enough regard for fire safety”Celestine Cheong, Fire Protection Association

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+ 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.

Zainab ChoucairMierna ChoucairFati ma ChoucairBassam ChoucairNadia ChoucairSirria ChoucairFirdaws HashimYaqub HashimYahya HashimHashim KedirNura JamalAnthony DissonMariem Elgwahry

Fati ma AfrasehabiSakineh AfrasehabiIsaac PaulosHamid KaniBiruk Haft omBrkite Haft om

Mary Ajaoi Augustus MendyKhadija SayeMalak BelkadiLeena BelkadiFarah HamdanOmar BelkadiJessica Urbano Ramirez

Sheila Smith

Steven Power

Abdeslam SebbarAli Yawar Jafari

Denis MurphyMohammed AlhajaliJeremiah DeenZainab Deen

Ligaya MooreMehdi El-WahabiNur Huda El-WahabiYasin El-WahabiFouzia El-WahabiAbdul Aziz El-Wahabi

Deborah LamprellErnie VitalMarjorie VitalMohamednur TuccuAmaya TuccuAmal Ahmedin

Vincent ChiejinaMohammed Abdul HanifMohammed Abdul HamidHusna BegumRebeya BegumKamru MiahKhadija Khalloufi

Marco Gott ardiGloria TrevisanRaymond BernardFathia HasanHania HasanRania IbrahimHesham RahmanMohamed NedaFathia AlsanousiAbufars IbrahimEsra Ibrahim

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controls in place to insist on that priority? Have we got a consolidated approach across the government and the sector? We’ve created gaps: not intentionally, but just by the nature of the complexity of the building process. The sticking plaster solution would be clearer guidance on material specifi cation, but that wouldn’t fi x the overall issues.”

At the Fire Protection Association, which had pressed the government to implement the recommendations of the Lakanal House coroner on re-writing AD B for clarity, spokes-person Celestine Cheong says that Grenfell highlights a “broken system”. “There was a systemic breakdown in fire safety regula-tion and governance. Decisions about design strategies, products, techniques, certifi cation, competency and auditing are made in a dis-jointed and often ineff ective and inconsistent manner, with less regard for fi re safety than should be the case.”

National cladding crisis It seems clear that multiple failures – from the council’s “value engineering” to opera-tional issues at London Fire Brigade – all

contributed to the Grenfell disaster. But the weeks following the fi re have seen a consist-ent focus on the materials used in the tower’s £8.7m refurbishment, following shocking video evidence of a strip of fl ame reaching up the corner of the building by 1.30 am on 14 June. The investigations might conclude that the fi re also spread within poorly-compart-mentalised fl oors, or in risers. But it seems obvious the blaze would not have been so deadly if the building had not been reclad.

The immediate questions on the Gren-fell refurbishment, which reportedly had 16 building control inspections from the council, soon widened into a national issue. A government testing programme found that at least 190 other high-rises featured rainscreen cladding that failed its combustibility test. If the Grenfell refurb team, led by contractor Rydon, had misinterpreted the Regulations, then so had hundreds of others across 51 local authorities.

The explanation is found in AD B, which has not been comprehensively revised since 2006. On 2 July, the Department for Com-munities and Local Government (DCLG)

explained that it expected the inner fi lling inside the Aluminium Composite Material (ACM) “rainscreen” cladding panels to meet a “limited combustibility” standard. But many construction teams – and presumably building control inspectors too – relied on an interpretation of AD B that suggested that a building’s external surface at heights over 18m simply had be “Class 0” for the spread and propagation of fi re. In the DCLG’s inter-pretation, the Class 0 “external surface” was the external face of the panel; others thought it referred to the entire panel as a whole.

As many have highlighted, AD B is very complex, off ering multiple alternative routes to compliance, and zig-zag references to appendices, tables and other guidance: hous-ing architect Julia Park, writing in Building Design, calculated that AD B makes reference to no fewer than 93 other documents.

Rudi Klein, a barrister and chief executive of the Specialist Engineering Contractors’ Group, says: “[Building Regulations] are not drafted in a prescriptive way, they don’t say ‘you shall’, they’re drafted in terms of out-comes. They need to be easily understood by

JUNE 1999Garnock Court, IrvineThe flats had been given

new of floor-to-ceiling unplasticised polyvinyl

chloride (uPVC) window units. When a fire started on the fifth floor, a vertical ribbon blazed. A 55-year-old man died. A House of Commons Select com-

mittee report questioned the fire tests under AD B at the time. In 2000, the Regulations were

changed, introducing the BS 8414 test. But other compliance routes and ambiguities remained.

FEBRUARY 2015Marina Torch, DubaiA fire started on the 51st floor of the 86

storey tower, thought to have been started

by a cigarette or shisha coal left on a balcony.

Eyewitness video shows large quantities of burn-ing material falling from a high-level fire starting

a secondary fire at a lower level. The Marina was among the 70% of the high-rise develop-

ments in Dubai clad with aluminium composite

material panels.

NOVEMBER 2014Lacrosse, MelbourneMore than 400 people were evacuated when a fire that started on

an eighth floor balcony spread vertically to the

roof within 10 to 15 minutes. The build-

ing was clad in 4mm aluminium composite

material (ACM) panels with a polyethylene

core, from Alucobest. Investigations found that they had not been tested

in accordance with the relevant Australian

standards.

MAY 2012Mermoz Tower, FranceThe Roubai x tower had been refurbished and

reclad nine years before the fire killed one person

and injured six. The refurbishment included adding metal compos-ite cladding above the

ground floor: the panels had a 3mm polyethyl-ene core sandwiched between two 0.5mm

aluminium sheets. According to one

researcher, residents were concerned about the quality of the refit.

DECEMBER 2015The Address, Dubai

Fire engulfed the 63 sto-rey hotel on New Year’s

Eve, the third major blaze in Dubai after the Tamweel in 2012 and the Marina Torch in

2015. Sixteen people suffered minor injuries. The cladding on The

Address was described by supplier Alumco as an ACM with a poly-

ethylene core material. Similar products were

used routinely in Dubai’s building boom, but were

outlawed in 2013.

+ CLADDING FIRE TIMELINE

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the people who put them in place and operate them. People know there isn’t much enforce-ment [from building control inspectors], and that creates a certain culture.”

For Roche, the question of how the Gren-fell team and the wider construction industry interpreted AD B will be at the “core” of the public inquiry. “What is Approved Document B and how does it fit? Is it law, or is it guid-ance? Then there is other guidance [from industry and manufacturers] and other routes to compliance. When you work to functional requirements, it opens the door to other routes,” he says. “The doubts at the heart of this are the reason we’re calling for a review [of AD B]. We need clarity, and on the wider issue of enforcement and competency, too.”

But such a widespread and safety critical misinterpretation of AD B suggests that the DCLG and its advisers – the Building Research Establishment has a contract to provide fire advice to it, and a panel of industry experts sit on the Building Regulations Advisory Com-mittee – were, at the very least, detached from what was actually happening in hundreds of construction projects across the country.

This ambiguity clearly demonstrates the urgent need to re-write AD B to improve clar-ity and meaning – a recommendation of the coroner in the Lakanal House inquest in 2013. It took the DCLG two years and pressure from the Construction Industry Council and Fire Sector Federation to accept that recommen-dation, a further year to commission a survey (by RIBA offshoot NBS) and another year to 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 to Hugh Robertson, health and safety policy officer at the TUC, is that it’s impossible for non-professionals to see whether or not the building they live or work in complies with statutory requirements. “It puts fire safety in the hands of the ‘experts’. The people who live

or work in high-rise blocks should be able to have a simple answer to whether their work-place or home is safe. If a building is being refurbished, the safety reps should be able to check it’s safe. The way the regulatory system works, so much is based on standards which are not accessible,” he says.

While the DCLG had made limited progress on clarifying AD B, it had also failed to deliver on a promise of a wider-ranging review, a pro-cess that would most likely have taken in evi-

dence on multiple fires around the world linked to polyethylene rainscreen cladding. “We were told we would see the review in 2016–17, but the government hadn’t yet gone out to consul-tation, and it takes at least 18 or 24 months of consultation to do it properly,” notes Roche. The RIBA is now calling for a “comprehensive,

transparent and funda-mental reappraisal [of AD B], rather than amend-ment or clarification, to ... provide clarity and protect public safety”.

Risk and reward The other side of the Grenfell’s failed safety net is fire safety regu-lation. In 2005, the Regulatory Reform Fire

Safety Order (RRFSO) brought the regime of fire risk assessments (FRAs), enforced by spot-check audits by fire and rescue services. Once, the reforms seemed statistically proven to be a success: Home Office figures suggest that although the number of audits was in decline, the number of fires was too (see p22). “The recent cuts to the fire and rescue services were predicated on things becoming safer,” says health and safety consultant Ashley Williams, who often carries out FRAs.

The statistics created false comfort, argues Roche. “Is Grenfell an anomaly, or an indication of an underlying trend that we need to take heed of? Many would say that just because we haven’t seen an event like this before, we need to ask what this is telling us about the built environment.”

Fire risk assessors point to a lack of cohe-sion between FRAs and construction checks, with gaps in enforcement. “I see building control failures all the time, things that an inspection should have picked up,” says Wil-liams. “There’s so much work done by sub-contractors, and who’s checking that the work has been done correctly? We find doors miss-ing their hinges; door frame casings missing; intumescent seals missing.”

And that’s the work the fire risk assessors can see, and not the roof spaces or service areas that the assessors either wouldn’t see, be qualified to make a judgement on, or have leverage over. “If I’m in a corridor with a false ceiling, I’ll lift up the panels, but I won’t climb in all of the ducting – that’s not the role of a fire risk assessor,” says Jonathan Backhouse, who explains that he follows the methodology laid out in PAS 7. In that situation, he says, he would recommend an additional study. But there is no legal mechanism to enforce the cli-ent to undertake such a study, far less act on it.

Many commentators compare the

It puts fire safety in the hands of ‘experts’. The people who live or work in high rise blocks should have a simple answer on whether their buildings are safe” Hugh Robertson, TUC

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+ A WARNING IGNORED

The parallels between Grenfell Tower and the Lakanal House fire in Southwark in July 2009 are clear. At Lakanal House, where six people died, the inquest established that a principle cause of the fire’s rapid spread – trapping the victims in two flats – was the inadequate fire resistance of the recently replaced exterior panels. Flames leapt from one flat to another within 15 minutes, confounding London Fire Brigade’s “stay put” policy and rescue attempts.

A construction project team (Southwark Building Design Services as project manager and Apollo as contractor) had taken a building with moderately good exterior fire resistance – the original panels contained asbestos – and weakened it.

But one reason why the Lakanal case did not resonate more strongly was that the panels were established to be non-compliant with AD B. Therefore, the coroner’s conclusion was that AD B itself was not at fault, rather there were problems with its compliance and enforcement.

On the other hand, the inquest demonstrated just how confusing and open to interpretation AD B could be, with one expert witness giving evidence that the panels should have 60 minutes’ fire resist-ance, only for the Department for Communities and Local Government to clarify that this was not the case. When Judge Frances Kirkham sent her Rule 43 letter to then communities secretary Eric Pickles, she therefore concentrated on the fact that AD B was so impenetrable. She described it as a “most difficult document to use in order

to find an answer to relatively straightforward questions”. Kirkham suggested that AD B should be reviewed to be “intelligible to the wide range of people and bodies engaged in construction, maintenance and refurbishment”, and also rec-ommended that AD B should provide guidance to assist those involved in the maintenance or refurbishment of older housing.

The coroner also pointed out that retro-fitting sprinkler systems in high rise residential buildings “might now be possible at lower cost than had previously been thought to be the case, and with modest disruption to residents”.

David Gold, chair of the IOSH fire risk man-agement group, says that international statistics show that following fires where sprinklers are involved, deaths, injuries and property losses are all significantly lower. “The sprinkler is one of the most effective tools we have. It’s far more effective than putting an extinguisher in someone’s hands,” he says.

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enforcement gaps in the current regime to the higher levels of enforcement pre-2005. “In the cases of a FRA, you just have it done, keep it and comply with the recommendations. In the past, the fire and rescue services inspected all properties and issued a fire certificate which stated ... what precautions a com-pany or organisation had to take,” says Cheong at the FPA.

Post-Grenfell, other shocking fail-ures in the fire safety integrity of social housing have come to light. At Cam-den’s Chalcots Estate, a “thousand” fire doors were either missing or ineffective, an issue that The Guardian believes came to light in 2012 but was not acted upon; in Southwark’s Ledbury Estate in Peckham, engineers were only sent to check serious structural cracking that comprised fire com-partmentation after the residents demanded action after the Grenfell fire.

The TUC’s Robertson says there had been a rising sense of complacency around fire safety. “Overall, fire safety has become less of a priority for everyone. The Fire Safety Order/fire risk assessment system only works if there’s an inspection support system, but risk assessments aren’t always checked.” David Gold, chair of IOSH’s fire risk management group, says that it cautioned the All Party Parliamentary Fire Safety and Rescue Group (APPFSRG) of a risk of complacency in 2016.

Williams argues that a lack of transpar-ency and statistical data is fuelling the lack of accountability. “The prosecutions [by regional fire services] are hidden on the website of the Chief Fire Officers’ Association; and what’s there isn’t in-depth,” he says, comparing the situation to the relative openness of the HSE’s prosecution database and press releases. “Fire safety is a difficult area at the end of the day, and lack of transparency doesn’t help.”

Evidence-based decisions It’s now clear that various branches of cen-tral and local government received direct warnings that fire safety standards in the UK were at risk: the APPFSRG, the Fire Sector Federation, the Fire Protection Association, insurers bodies and the London Fire Brigade all sounded the alarm at various times. But why did none of these attempts – singly or in combination – trigger a government response?

The Fire Sector Federation’s Roche tries to explain. “I wouldn’t say that it was like howl-ing at the moon. People listened. But what we recognise about government is that we need to give evidence: any call for change gets a ques-tion back, which is ‘show me the evidence’. We hadn’t seen action from government, but on the other hand no one was saying no.”

And gathering the necessary “evidence” would not have been easy: there is no chan-nel to filter the experience of building control departments to government, or to aggre-gate the findings of fire risk assessments. Another complication, Roche adds, is that fire

regulation is split between government depart-ments: the fire service and the RRFSO is under the Home Office; Building Regulations are under the DCLG; schools are under the Depart-ment for Education; and the NHS falls under the Department of Health. “How do we join all these up within government?” he asks.

Industry bodies had attempted to step in where government had failed to act: Roche’s Built Environment Affairs and Issues work-stream had been “working on issues around the wording of AD B, such as have we got the definitions right?”. Its interim report was due to be launched on June 15 at Firex. “It was part of a strategy to say we need to push gov-ernment for the review of Part B because it’s taking too long,” says Roche.

At the FPA, Cheong was involved in pro-ducing guidance that was never released,

which may have addressed some of the issues raised by fire risk assessors. “There was new Building Control and Fire Safety Procedural Guidance produced over two years ago, overseen by the Fire Sector Federation and checked by DCLG’s legal team and placed in line for publication. However, we have not seen this accomplished to date.”

At the Association for Specialist Fire Pro-tection (ASFP), chief operations officer Niall Rowan says that building projects are often inadequately inspected for fire safety, in part due to the number of firms, including third party assessors, involved in a project. “Building control sometimes inspect for fire safety and sometimes they don’t. There are many situations where the fire stopping is not inspected, and contractors know that.”

A year ago, the ASFP decided it had seen enough evidence of poor enforcement to take action. It was working on the introduction of a new “sign off” stage in the RIBA’s Plan of

Works, a road map for construction projects. The individual certifying that the works were in accordance with all fire safety considerations would incur legal liability if things went wrong. And if the technical or material speci-fications were later changed – as in the kind of “value engineering” exercise that apparently happened at Grenfell – then further sign-off would be needed.

The first draft of its “Construction Strategy” was due to be launched at Firex, but was postponed. The ASFP’s Rowan says it is now seeking as wide a group of stakeholders as possible to participate in drafting a workable

strategy for the industry.

The new realities As everyone involved in health and safety adjusts to the new realities post-Grenfell, where faith in our regulatory system no longer seems quite so well-founded, opinion is split between calls for more regulation, or simply far better enforcement and monitoring of the regulations we already have. At the TUC, for instance, Hugh Robertson says it’s too soon to judge whether the RRFSO system is still fit for purpose, or if the failings lie elsewhere.

Rudi Klein, however, calls for a re-think on Building Regulations. “Because of pressure on local authority resources, there’s a general lack of enforcement of regulations and stand-ards. The bulk of the Regulations are aimed

at public safety, wel-fare and wellbeing, so why not have a national enforcement regime?”

Rowan identified the pressures faced by build-ing control departments, shrinking due to auster-ity measures while sub-ject to competition from private sector approved inspectors. The GMB,

meanwhile, has revived a debate on licensing construction contractors to raise public safety.

Cheong calls for more research, and more reviews of the regulation we rely on. “Keeping pace with technical developments and learn-ing from real events is essential in the fire sec-tor, it’s the regulatory framework that hasn’t kept up.” Roche is also looking to the future. “If we build combustible buildings today, we have to live with them for 30 years unless we’re prepared to rip things apart. The sta-tistics might not change for years if we build buildings at risk today.”

What seems certain, however, is that the post-Grenfell world will need a new ap proach to fire safety, which recognises that existing regulations were both too complex and not sufficiently updated; that there were gaps in accountability; and that enforcement either wasn’t comprehensive or acting as a sufficient deterrent. And above all, that getting these issues right is what keeps people alive. n

Any call for change gets a question back, which is ‘show me the evidence’. We hadn’t seen action, but no one was saying no”

Thomas Roche, Fire Sector Federation

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+ INSPECTIONS AND FIRES

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10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

2010/11 2011/12 2012/13 2013/14 2014/15 2015/16

Dwelling fires

Non-dwelling fires

Audits