Grenfell Tower Inquiry

On 29 June, May announced that Sir Martin Moore-Bick, a retired judge, would lead the inquiry. She stated that "Before the Inquiry starts Sir Martin will consult all those with an interest, including survivors and victims’ families, about the terms of reference." Moore-Bick met some survivors of the fire that day, and cautioned against giving the inquiry too much scope.[13]

The appointment was met with some criticism from survivors, as well as Emma Dent Coad, the MP for Kensington. The chief criticisms were towards Moore-Bick's background in commercial law, his different social background to the survivors and his previous ruling in a Westminster City Council case, in which he had allowed a local resident to be rehoused 50 miles away. This decision had been overturned on appeal by the Supreme Court.[14] Dent Coad said "We need somebody who can do the detail but we need somebody who can actually understand human beings as well."[15] During two public meetings held by the Inquiry before the finalisation of the terms of reference, various residents criticised the lack of diversity of the Inquiry panel, saying that it did not represent the community.[16]

An anonymous legal columnist in the New Statesman wrote that "The bulk of this objection, it appears, arises out of a rapidly cultivated image of Sir Martin as an establishment Mr Whitewash." The columnist argued that Moore-Bick's background as a "fact finder" in commercial law made him far better suited to the role than a criminal judge, and that getting the inquiry to empathise with the survivors "can be achieved without sacking the chair and starting again."[14] Lord Chancellor David Lidington said Moore-Bick would lead the inquiry "with impartiality and a determination to get to the truth and see justice done".[15]

The inquiry leadership held a consultation on the inquiry's terms of reference throughout July 2017, which concluded on 4 August.[17]

On 30 June, Labour Party leader Jeremy Corbyn wrote to May to say that the inquiry's terms should be broad, because the fire had "much wider implications for national policy issues".[18] Former Lord Chancellor Lord Falconer said that "The inquiry has got to look at how [the regulatory] regime developed, or I think the residents would feel they were let down."[18] On 17 July, he again to May, saying: "As I set out in my letter dated 30 June, there is considerable concern among residents and others that the judge leading the inquiry has already been directed towards a narrowly defined Terms of Reference, which will not bring residents the answers they seek."[19]

On 15 August 2017, Theresa May announced the terms of reference. The inquiry's role would be to examine "the circumstances surrounding the fire", including its causes, how it spread to the whole building, and the adequacy of the regulations and safety measures in place.[5][20]

Labour Party politicians and some survivors have argued that the inquiry should include an examination of national policy in national policy towards social housing.[21][22][23] In his letter to Theresa May proposing the Terms,[24] which were agreed without amendment,[25] Moore-Bick had noted that many of those affected by the fire and others had been in favour of this. He argued, however, that this would add significantly to the time required to complete his work, and that such an examination was better suited to a different kind of process and not to a judge-led inquiry.[24] in her response, Theresa May said that the Housing Minister Alok Sharma would "personally meet and hear from as many social housing tenants as possible" both in the immediate area and further afield.[25]

In response, Corbyn wrote an open letter to May saying: "The fire has raised profound concerns about the way that social housing is provided and managed in this country, and I as well as many survivors worry that without a wider focus, the inquiry will fail to get fully to grips with the causes of the fire." Corbyn also said May should "immediately set out a clear, independent and thorough process for identifying and addressing the broader failings that led to the Grenfell fire."[26] Matt Wrack of the Fire Brigades Union said, "Central government has created the housing and fire safety regime and central government must be held to account for any failings in it. Yet the terms of reference signed off by Theresa May appear designed to avoid this."[27]

Two former panel members from the Independent Inquiry into Child Sexual Abuse raised concerns about the ability of the inquiry to be independent of the government.[28]

Matt Wrack, the general secretary of the Fire Brigades Union, argued that the order of the inquiry made the fire service's role too prominent, while other issues will be addressed in the second phase when public interest will have faded.[29]

On 7 January 2018, an open letter to the Prime Minister signed by 71 academics and several politicians was published. This described concern for a possible conflict of interest of the auditors KPMG, who audited the Royal Borough of Kensington and Chelsea and companies responsible for the cladding on Grenfell Tower. This was viewed by signatories as a conflict with their neutrality on the enquiry.[30] In response, KPMG agreed to immediately withdraw from the enquiry and waive its fees.[31]

Evidential hearings began on 4 June 2018. The first week saw opening statements on behalf of the key organizations and the presentation of reports by key expert witnesses.[36] No hearings were held in the week beginning on 11 June 2018, as the anniversary of the fire and commemorations fell within this week. The hearings resumed on 18 June 2018.

The appointed expert witnesses were:[37]

• Dr Barbara Lane, a fire safety engineer from Arup[38]
• Colin Todd, a fire safety consultant from CS Todd & Associates
• Professor David Purser, from Hartford Environmental Research
• Professor Edwin Galea, Professor of Mathematical Modelling at the University of Greenwich
• Dr Ivan Stoianov, Senior Lecturer in Water Systems Engineering at Imperial College London
• Dr J. Duncan Glover, from Failure Electrical
• Professor José L. Torero, Director of the Center for Disaster Resilience, University of Maryland, USA
• Professor Luke Bisby, Professor of Fire and Structures at the University of Edinburgh
• Professor Niamh Nic Daeid, from the Centre for Anatomy and Human Identification, University of Dundee
• Rodney Hancox, Director, Gas Distribution Solutions
• Steve McGuirk, former Chief Fire Officer of Greater Manchester, Cheshire and South Yorkshire, former President of the Chief Fire Officers Association, and former Lead Adviser to the Local Government Association

The witness statement from the resident of Flat 14 (where the fire started) was published. He reported he had been harassed by the media. His lawyer had requested that the inquiry's report should specifically exonerate him.[39]

The London Fire Brigade incident logs were also published. Among transcripts that are to be cross-examined in week five, the "operational response" reveals that more than 140 fire engines and 720 firefighters were deployed; deputy assistant commissioner, Andrew Bell, told the inquiry on Thursday that it was probably the largest deployment of breathing apparatuses ever made in the UK.[40]

Evidence from the firefighters and fire officers was heard from 25 June to 2 October, with a gap in August.

The first to testify was Watch Manager Michael Dowden, the initial incident commander. His testimony lasted three days. He admitted that he had been unsure how to respond when the fire began climbing up the side of the building.[41][42][43] Some of the questions he answered were repetitious – as they had been independently asked by the victims families. He could not continue when Richard Millett QC, counsel to the inquiry asked about a 12-year-old girl.[43]

Moore-Bick praised Dowden for his three days of testimony, saying he had shown "courage and candour". The Fire Brigades Union described the line of questioning about Fire Brigade Policy as "at times absurd" given Dowden's relatively low rank. Matt Wrack, the FBU general secretary said, "There clearly are important and difficult questions to ask but they should not be directed at those who do not have the power or authority to have altered policies, operational procedures or training,"[43]

The first firefighters and officers to testify were among those who were first to respond, [44][45] followed by others including senior command staff. Several firefighters reported being in life-threatening situations and felling emotional trauma after being unable to rescue certain residents.[46][47] Control room staff also testified.[48]

Issues discussed included communications problems,[49] the sheer amount of smoke,[45] the stay put policy that was eventually abandoned,[50] equipment shortages[46][51] and missing fire safety features in the building such as floor plans.[52]

Dany Cotton, who had been the brigade's Commissioner since January 2017, testified on 27 September. In response to questions about LFB's preparedness, she said the disaster was as unexpected as "a space shuttle landing on The Shard." She also said that "I wouldn't change anything we did on the night." These remarks draw criticism from survivors groups. [53]

The inquiry also heard from representatives of the Kensington and Chelsea Tenant Management Organisation (KCTMO). [54] KCTMO's lawyer said that although the building only had a single stairway "it managed to continue supporting evacuations and firefighting activities throughout the life of the fire" and that expert evidence suggested that 239 people could have got out after seven minutes.[55] She said, "The inquiry will want to consider that the stairs at Grenfell Tower could have coped with a full building evacuation." They remained operational throughout the fire; 239 people could have exited within seven minutes if so instructed. Expert Dr Barbara Lane, had said the stay-put policy effectively failed at 1.23 am, but it was kept in place until 2.37 am when 107 people were still inside; 36 lived.[55]

It was revealed that in July 2014 an official from KCTMO emailed the project team: “We need good costs for Cllr Feilding-Mellen.” At that point £300,000 was removed from the cladding budget and zinc panels were replaced with the aluminium composite material with a plastic core, which the government has now banned from use on high-rise residential blocks.[54]

The barrister for Arconic claimed that the Reynobond aluminium composite panels cladding had not been responsible for the disaster. If the replacement windows and sub frames had been installed correctly the flames from a simple kitchen fire could not have bridged the gap into the cladding, and could have been put out with a simple fire extinguisher.[55]

Martin Seward counsel for the Fire Brigades Union said that the Royal Borough of Kensington and Chelsea had failed to make an evacuation plan for Grenfell Tower and relied on an outdated "stay put" strategy, leaving it to the fire brigade on the ground to devise an evacuation strategy. He urged the inquiry to give his members from "protection from unwarranted criticism".[55]

Sir Martin Moore-Bick issued the first part of the report Wednesday 30 October 2019, though some parts had been leaked days earlier.[56] He found that:

• The resident of the flat where the fire started was not at fault.
• The principal reason the fire spread was the aluminium composite cladding filled with plastic used on the building exterior.
• Firefighters showed "courage and devotion to duty" and 999 call operators were "unstinting" in their efforts to help trapped residents.
• Incident commanders were not trained to cope with the fire and there was no contingency plan for evacuation.
• The LFB failed to lift the "stay put" advice when the stairs remained passable, which cost lives.
• The brigade suffered "significant systemic failings".
• Communications systems failed and there were serious deficiencies in command and control.[56]
• Pictures transmitted on the night of Grenfell could not be viewed by the LFB because the encryption was incompatible with its receiving equipment.[57]

He highlighted Dany Cotton's rhetorical question "It's all very well saying 'get everybody out', but then how do you get them all out?", saying that it demonstrated that the London Fire Brigade had never considered that question before the night of the fire.[57]

On 6 December, Dany Cotton announced her early retirement effective from 31 December 2019 after 32 years of service. This followed calls from bereaved families and survivors of the disaster for her to quit.[58]

Campaigners had argued that the inquiry should include an advisory panel to assist Moore-Bick.[59] In May 2018, it was announced that two panelists would sit alongside Moore-Bick for the second stage of the inquiry.[60]

There was certain disquiet that phase two would not address the bigger issues of race and class discrimination and the austerity-driven housing crisis believed to have underpinned the disaster. Replacing on the panel, an expert on social housing with an engineer, was seen by Grenfell United and the Hillsborough families support group as evidence that their views were about to be sidelined. “They are not listening and they don't want to listen,” said Nabil Choucair. “The inquiry should be designed to look at the aspects we want them to look at.” Choucair lost 6 relatives in the fire.[61]

Phase 2 is expected to take 18 months. 200,000 unseen documents, from private emails to phone transcripts and commercial agreements, will be released, illustrating decisions taken by the May government, borough councils, and private companies in the months before the fire, and in the immediate aftermath.[62]

A second allegation of conflict of interest surfaced in January 2020. A few weeks earlier, one of the phase 2 panelists had stepped down and Prime Minister Boris Johnson (who had succeeded May in July 2019) appointed Benita Mehra to fill the post.[63] Mehra was the chair of the Women's Engineering Society charity from 2015 to 2018. The Guardian reported that in 2017 the charity had received a £71,000 grant from the Arconic Foundation, an organisation linked to Arconic, the manufacturer of the panels. Mehra helped draft the application for the grant, which was the largest donation the charity had received that year.[64] Following criticism from opposition politicians and survivors,[7] Mehra expressed regret for her oversight, and resigned on 25 January.[65]

Phase 2 will be divided into eight modules:[66]

1. The 2015-16 refurbishment
2. The testing, certification and marketing of the cladding panels and external insulation
3. The management of Grenfell Tower, including how residents' complaints were handled
4. Central and local government responses to the disaster
5. The response of London Fire Brigade
6. Building regulations and enforcement
7. Remaining expert evidence
8. Remaining evidence from bereaved, survivors and residents

The second phase of the inquiry opened on 28 January 2020 at a new venue in Paddington, at 13 Bishop's Bridge Road, London, W2 6BU,[67] with Arconic's lawyer making a statement.[7]

The second phase opened with statements from lawyers for Studio E, the architects of the refurbishment; Rydon and Harley Façades, the buildings; Celotex, who had made the combustible insulation; and Arconic, who had supplied the ACM panels.[68] There were also statements from the Royal Borough of Kensington and Chelsea (RBKC) and the KCTMO.

Lawyers for Rydon introduced emails that showed that Celotex knew that their combustible insulation product was not safe to use with ACM panels as a suitable fire barrier was not available. They produced internal emails from Arconic from 2011 showing that the fire-rating of their Reynobond PE (polyester filled) panels had dropped to class E from class B and so were "unsuitable for use on building façades" in Europe. [68]

The combustible cladding panels made by Arconic, which contained the flammable polyethylene core, were chosen as part of an attempt to cut £454,000 from the budget by KCTMO. The architect, builders and fire engineer who worked on the refurbishment knew the cladding system would fail in the event of a fire more than two years before the blaze, in conditions where the fire flamed through windows. The lawyers for Celotex introduced an email thread where Daniel Anketell-Jones of Rydon, discusses the need for a fire stop in the cavity and this was copied and discussed by the other organisations involved. [69]

After the companies' opening statements were read, Richard Millett criticised them for failing to admit any mistakes: "With the sole exception of RBKC, not a single core participant involved in the primary refurbishment of Grenfell Tower has felt able to make any unqualified admission against its own interests." RBKC had admitted its building control body had made errors, while Celotex admitted its marketing of the insulation had been misleading. The Times suggested that the companies' response had been to "blame each other."[70] Millett added: "Any member of the public reading these statements and taking them all at face value would be forced to conclude that everyone involved in the refurbishment of Grenfell Tower did what they were supposed to do and nobody made any serious causative mistakes."[71]

On day three and four, witnesses involved in the tower's refurbishment have asked for confirmation that any evidence they give will not be used against them in any criminal proceedings that might take place, before they will give evidence.[72][73] At the hearing on 6 February, the chairman ruled that the inquiry should be suspended till at least 24 February to allow the attorney general Geoffrey Cox time. He explained to the victims and families that the right not to self-incriminate was enshrined in English law. This is not the same as being given immunity from prosecution.[74] However the suspension dragged on with the Attorney General wishing to ascertain how many witnesses would demanding immunity, and the chairman pointed out this was of the greatest urgency as a health and safety issue affect hundreds of lives.[75]

On 2 March, a further attempt was made to reopen the enquiry. The attorney general had given the assurance, and Moore-Bick explained that the undertaking meant that “no one will be able to justify refusing to answer questions on the grounds that to do so would or might expose him or herself personally to a risk of prosecution”. Community activists protested loudly that “It's one rule for them and one rule for the firefighters,” and “It means the firefighters were hung out to dry. It's a whitewash. It means the inquiry is a whitewash.” Later, Andrzej Kuszell of Sudio E, the architects admitted that refurbishing tower blocks was “something that was not within our normal experience”.[76]

This started with evidence, from Studio E. A lot of this was about who knew what, and whether they were qualified to do what they did. On 3 March 2020 the enquiry heard:

• The lead architect had no experience of cladding high rise buildings or polyethylene composite materials.(cladding)
• The Point of contact was not a qualified architect.[77]
• Sounes, the architect said he had “no knowledge” of rapid fire spread and had not read regulatory guidance about how to the design cavity barriers that were intended to stop fire spread and which failed at Grenfell, believing that it was Building Control's job to check his drawings for compliance. He had not heard of Lakanal, or that aluminum cladding could burn.[77]
• An email was produced from Kate Cooney of Exona the fire consultants, four years before the project was signed off, suggesting that they are concerns about the safety of the (FF/MoE) Means of Escape shaft- but they could massage the scheme to mitigate the dangers, but the existing tower was already not safe. Sounes expected that as building control had signed off the system then it was acceptable. Sounes was taken ill and was not cross-examined further.[78]

Neil Crawford, the lead architect for Studio E, revealed that Studio E had been on the point of terminating Exona in 2012 for failing to adequately scrutinise early proposals, and that a promised report on the safety of the revised cladding never arrived. In Crawford's opinion, Celotex had actively tried to deceive by saying, in an architect's information sheet, that the material was “acceptable for use in buildings above 18m in height” whereas in fact that statement actually referred to a different product. Crawford used the metaphor that 'it was passing off horse meat as beef'.[79]

In the light of the Prime Minister's statement on the afternoon of 16 March 2020, the panel decided on the same day to hold no further hearings for the time being.[80]

Due to the COVID-19 pandemic social distancing rules now in place, not all the members of the public who wished to attend were allowed to do so, but were able to view the proceedings via a video link.[81]

The inquiry heard claims that during the planning process Simon Lawrence, a key executive of Rydon, failed to respond to concerns that the cladding might be dangerous and that it could lead to a repeat of the Lakanal House tower fire in south London in 2009 which caused the death of six people.

Project emails show that Rydon, Exova, and the architects Studio E discussed the fire safety of the cladding before its installation, including warnings it might fail. Tony Pearson, of Exova, told the architects: “If significant flames are ejected from the windows, this would lead to failure of the cladding system, with the external surface falling away and exposing the cavity.”

The inquiry was told that in November 2014, an official at KCTMO asked Simon Lawrence to clarify the “fire retardance of the new cladding” but that Lawrence did not respond.[81]

The inquiry also heard that Studio E manipulated its fees to avoid the contract being put out to open tender.[81]

The enquiry heard the fire engineer, Terry Ashton of Exova, say that his responsibilities on the project had been limited to the reconstruction of the tower, and not on the plans to reclad it. He said he had received a large envelope from Studio E that contained the drawings and plans for the recladding, but that he had not opened it. He said that a package containing information on new rainscreen cladding, curtain walling and replacement windows was sent, that he had been asked to “look it over” but that he had not done so. He said that he had also not thoroughly read the building guidelines "BR 135 guidance on fire spread in external walls". He said he had never visited the site but despite this that he had written the Fire Strategy document referred to by the design team at Studio E .[82]

Building Consent was explored. RBKC had a reputation for sticking to the letter of the regulations. Obtaining building consent is seen as being a process of negotiation. One proposal is put forward and a compromise reached. RBKC were adamant that the new wall structure must include fire stopping barriers with a two-hour rating. Studio E architects found this unnecessary claiming the job was done by the cavity barriers.[83]

Chris Holt, Rydon's site manager attested: “I was aware that as the refurbishment was to a residential block of flats, one of the main risk factors would be fire safety. When I started on the project I spoke to Simon Lawrence (Rydon) and asked whether I was required to consider aspects of fire safety in my role. Simon informed me that it was not part of my role and had been dealt with.” [84] Rydon did not normally employ specialist fire consultants and felt “comfortable with the risk”, as it had done before on social housing blocks: they believed they were using competent specialist sub-contractor.[84] Rydon had assured RBKC and the architect that they were employing a fire expert in meetings in April, June, July, September and October 2014. Thus the cladding material had been chosen without consulting a professional. Lawrence confirmed this.[84]

Simon Lawrence, an executive of Rydon, the principal contractor was testifying. He explained he knew that RBKC was attempting to save £800,000 on the job and to win the contract offered to save £293,368 by switching from the originally specified zinc cladding to the plastic-filled aluminium panels. The bid was accepted. Lawrence was not aware of the increased danger and hadn't researched it. However, the saving was £419,627, but this was never mentioned to the client. Rydon itself had undercosted the job and was trying to make up a £212,000 shortfall.[84]

David Gibson, head of capital investment from KCTMO [landlord] recalls making a spelling correction to the minutes on a meeting with Rydon in early 2015. Those minutes cannot be found. He recalls raising the panel safety issue with Lawrence who said the plastic-filled panels were inert. Lawrence denies having said so. There were discussions on the optimum fixing system, KCTMO held out for the more expensive "cassette-fix" which gave a smoother finish while Lawrence tried to persuade them to save £75,000 by using the 'face-fix' method. [85]

The enquiry began to examine the contractors onsite behaviour. It heard that the contractors referred to the residents who criticised their workmanship as rebels and aggressive rebels. There were claims that the residents had threatened the contractors, who were using inappropriate behaviour and language on site In an email, Lawrence of Rydon admitted that the site was “poorly performing” and they were using “cheap incompetent sub-contractors”. Reed of KCTMO found Rydon complacent, Rydon had given the job of packing the window gaps with fire-resistant Rockwool to a former employees company, and was not aware they had substituted cheaper flammable material. KCTMO was aware that the Residents Association was dissatisfied with the work, and one of their number had predicted the effects of the fire 14 months previously. He was labelled as aggressive. The contractors didn't clean up after the job and accused the residents of having made the mess. Lawrence in a contemporary email said there were missing finishes and gaps and he thought it was “a disaster”. He was not aware that there were window lining regulations he should adhere to.[86]

Evidence was given by the project manager Ben Bailey, 23 at the time, the son of the owner of Harley who were sub-contracting for Rydon. Celotex RS5000 came on the market as he was sourcing materials, He was not aware that changing materials for the project required consent from Rydon which had not been obtained. He said the only assessment of its performance that he saw was of its thermal insulation, not its fire performance - he was not aware that it was his job to check that. He obtained a 43% discount as Celotex wished to use the tower as a case study.[87] Celotex only guaranteed the safety of the insulation in the configuation they had tested and not for use with flammable plastic-filled aluminium panels. That caveat was missed by Bailey. Bailey said that had no training in understanding building regulations or in keeping up-to-date with industry codes of practice for the design and installation of cladding and windows. He said it was never his role to be considering the fire performance of the materials."[87]

John Rowan & Partners supplied two clerks of works to the project. One as a mechanical and electrical systems clerk of works – Tony Batty – and a general building clerk of works, Jonathan White. They were not employed to fulfill an end to end role but to act as part time consultants.[88] Rydon had a design and build contract and was responsible for the quality of its finished work. The John Rowan clerk of works were there to provide site monitoring and supervision services.[88]

The enquiry took evidence from Mark Dixon of SB Plastering on the window reveals. The window reveal is the surround of a glazing unit perpendicular to the glass. The glazing unit creates an interior reveal, and an exterior reveal, the top is known as the head, the bottom is the sill and the sides are called the jambs.[89] In the job, the window was moved outward and reduced in size. Dixon understood that his role was to create new interior reveals- in effect a purely cosmetic job. He agreed with Rydon to use rigid insulation board. (flammmable UPVC) He had not consulted building regs or confirmed the plan with the architects. He assumed that others would have checked.[90]

John Hoban, senior building control surveyor at the Royal Borough of Kensington and Chelsea (RBKC), reported councillors had signed off substantial cuts to the building control department. It was “swamped” with work as austerity-driven cuts slashed the staff numbers. The key surveyor was left managing handling 130 projects. He was assigned Grenfell Tower, which should have been handled by a senior officer. He had never worked before on highrise overcladding of a block. He had resigned before the fire because he had “had enough" and it wasn't the job he trained to do.[91]

The council-owned tenant management organisation, the architect, main contractor and cladding contractor assumed the council's building control department was ensuring that refurbishment did comply with the building regulations. Hogan was unaware of that, or about a series of fire risks embedded in what was designed and built.[91]

Hoban had received no training or technical industry guidance and said reading professional magazines was considered as their continuing professional development. He had not read the document about the fire performance of external thermal insulation for walls of multi-storey buildings known as BR135.[92] It detailed a 1999 cladding fire in Garnock Court in Irvine, Scotland, and explained with pictures the rapid fire spread through cladding, and he was not aware of the guidance differentiating between non-combustible panels made from materials such as cement and combustible panels, including aluminium panels which may melt and create molten debris.[91]

Hoban had made handwritten notes and handwritten project sheets and remembered putting all his notes into the Acolaid system, including coming in at the weekend to do so. These were now all missing.[91]

Hoban identified two problems that afflicted his department and had led to the fire safety aspects of the cladding being missed. These were the austerity cuts between 2013 and 2017, that had lead to 10 experienced officers being replaced by one graduate trainee, and the stripping back of building regulations and enforcement byelaws together with a weaker building act. He said, “If we had a regulatory body like we had with the Greater London council and the regulations and building act and bylaws we had at the time, and a support network of experts that administered the regulations, I don't think we would be here. ...”.[93]

The owners of the block, RBKC had delegated all responsibility for maintenance to the TMO, the landlord, so deny any responsibility for the disaster. The TMO claim that their choice of contractors for the refurbishment, decided by competitive tender, were blocked as RBKC had underpriced the job, and it would be significantly over budget. The objectives changed as price became more important than quality. Rydon were selected.[94] The landlord rejected a 30,000 offer to inspect the exterior of the tower for building regs compliance- doing it itself to save money.[95]

The first contractor appointed reported that it couldn't do the job for the amount tendered and it was to require a further £1.5 million. The second contractor appointed was Rydon. Rydon's refurbishment manager, Stephen Blake, and Peter Maddison, the TMO's director of assets, had a longstanding professional relationship. At an un-minuted meeting in March 2014 TMO and Rydon agreed how a further £800,000 could be shaved off a contract awarded to Rydon – this could be contrary to EU tendering law, being named value engineering. Rydon was given the contract [96] Maddison revealed that he still had his diaries and notebooks for the period, these were presented to the court, and transcribed. He had been told to hold on to them earlier, but had never previously been asked to hand them over.[97]

Madison, of the TMO explained the process used in these contracts and how he had delivered the project on budget, a sign that the contract had been correctly priced. He was not aware that the panels were flammable. A further 50% reduction had been extracted from the manufacturer, and Rydon had reduced its price by a further £800 000.[97]

Claire Williams, who worked for Grenfell landlords the Kensington and Chelsea Tenant Management Organisation (TMO), left her job a year after Grenfell. She said she had cleared her desk, destroying earlier notebooks. She did not think anything important could have been lost as the important points had been recorded in the official minutes.[98]

On 4 Nov 2020, the inquiry started to examine the manufacturing, safety, testing and marketing of the cladding products. Barristers for the victims, in their opening statements repeated the charges that:

• Arconic, which made the cladding sheets that were the main cause of the fire's spread, obtained a certificate for its plastic-filled panels on “a false premise” by supplying test reports for a more fire-retardant version of the product.
• Celotex, which made the bulk of the combustible foam insulation used, displayed a “widespread culture … of ignoring compliance”, which included distorting a full-scale fire test of its materials.[99][100][101][102][103] A former Celotex manager who had been involved agreed that the company's actions were "deliberately misleading and dishonest", saying he had been made to "lie for commercial gain" with the approval of Celotex's senior executives.[104]
• Kingspan, which made the rest of the insulation, carried out tests that involved either “concealing components in a manner designed to facilitate a pass and/or using materials that were not as described in the test reports,”[105][106]

It was claimed by the barristers that the companies viewed the safety certificates as marketing tools and of little other importance. A research paper by Saint-Gobain, the parent company of Celotex, said adding fire retardant to the test samples was done “in order to pass unrealistic fire safety tests”. Stephanie Barwise QC explained that this demonstrated that “Each of the[se] manufacturers fully appreciated the inherent flammability of their products and unsuitability for use over 18 metres, as was illustrated by events.”[105]

Evidence was produced that the three manufacturers were aware of the deficiency of their product and worried about preventing these facts damaging their marketing and sales.[107][108]

On 11 November 2020 it was revealed in a conflict of interest statement, that subsequent to the fire, the Ministry of Housing, Communities and Local Government (MHCLG) is awarding a £600,000 research grant to a consortium whose members include a fire testing specialist Eric Guillaume, whose research was funded by Kingspan, and José Torero, a fire engineer who has publicly opposed outright bans on combustible materials. There is a rival consortium for the grant stronger credentials in the field of smoke installation and toxicity. There was no open competitive tender the contract was let through the Crown Commercial Service system. [109]

On 16 November, Jonathan Roper, a former assistant product manager for Celotex, who worked on two fire tests of the foam panels and the subsequent sales plans, said the company behaved in a “completely unethical” way. When the first test failed, they re-tested inserting additional fire retardant panels. [110]

A senior technician, Ivor Meredith, responsible for safety tests on combustible insulation used on Grenfell Tower, had “a serious drug habit” and fell asleep at work. He had used drugs from 2010. Kingspan, his employer, knew but the problem was “brushed off” until he was sacked in 2015. Meredith help his employer sell its K-15 Kooltherm phenolic foam insulation, writing letters to clients saying it was suitable for use on high-rise buildings. After Celotex, which they also knew was selling a flammable product, came onto the market competing against their own K12, he managed the testing and certification.[111]

On 30 November 2020, the inquiry learned that Kingspan director Philip Heath had said, in 2008, that consultants who raised concerns about the combustibility of its product could "go f*ck themselves", and that they were "getting me confused with someone who gives a dam [sic]".[112]

A Celotex executive, Deborah Berger, says she was shocked by firm's approach to test three years before blaze and wrote the acronym WTF in the margin of the test report in 2014 when she discovered that the fire safety tests had been rigged.[100] The modifications were not included in the marketing literature relied on by architects.[101] A photograph of the test rig showed the inclusion fire-resistant magnesium oxide panels.[99] She reported her concerns to her line manager but later, still uncomfortable, helped word the documentation that was submitted to the Building Research Establishment for product approval.[113] The photograph showing the fire-resistant materials was later removed under pressure from Celotex.[99]

In an opinion piece written for the Guardian, Karim Mussilhy of the Grenfell Survivors Group, commented. " the fire at Grenfell Tower was no accident – it was the result of years of neglect, deregulation and corporate greed." He complained about he scale of the dishonesty and the silence in much of the national media and at the top of government. The materials are on thousands of homes, schools and hospitals across the country. While homes that cannot be sold are wrapped in flammable materials, Celotex, Kingspan, Arconic and BRE still operate as if nothing happened. No arrests have been made and some key Arconic executives are even refusing to attend the inquiry.[114]

He reminded them that Celotex and Kingspan made and sold the insulation and Arconic made and sold the cladding. From the evidence given to the inquiry that Celotex and Kingspan “abused” the fire safety testing regimes and Arconic acted similarly. The privatised Building Research Establishment did not pick this up which question their other judgements. [114]

Three of the Kingspan directors had been awarded shares as part of a 2018 bonus package. Predicting a share fall when the truth was revealed, they traded in these shares in September and October 2020. Gene Murtagh, who manufactured the panels, made a £3.1m profit, followed by the executive directors, Gilbert McCarthy and Peter Wilson made £1.8m and £1.6m respectively. [115]

On 8 December 2020, the inquiry saw evidence that in November 2016, Kingspan technical staff had acknowledged internally that Kingspan was selling its Kooltherm K15 foam insulation product as less flammable than it really was.[116][117] [118] A version of K15 had correctly tested safe in 2005, but Kingspan had changed the formula for a more flammable foam; marketing it on the old safety certificate.[119] [120][121] Kooltherm K15 was present in the cladding that caught fire.[122]

On 9 December 2020, the inquiry learned that after the Grenfell fire, Kingspan had invested in a smear campaign against rival companies' products. The campaign involved secretly using non-standard test rigs to artificially create the appearance that non-flammable rival products might in fact be flammable, and hiring lobbyists to push the results before policymakers such as the Housing, Communities and Local Government Committee and other MPs.[123] [124] [125] [126]

Three key witnesses have refused to testify, and are hiding in France, citing a legitimate 51 year old French blocking statute as an excuse for refusing to attend the inquiry. They were employees of Arconics. On Monday 14 December , Grenfell United delivered a letter appealing to the French Ambassador, Catherine Colonna, to exert moral pressure. A van displaying a red white and blue tri-colour poster drove past the embassy in Knightsbridge. The white panel was replaced by the emotive image of the burnt-out tower.[127]

During the adjournment, Peter Wilson, managing director of Kingspan's insulation boards division and director of the plc announced he was stepping down, and Gene Murtagh, the chief executive, told staff the company was trying to ensure “weaknesses in our testing and marketing of K15 can never be repeated”.[119]

There were 46 recommendations embedded within 35 paragraphs of chapter 33 of the four-volume full report, and published again in the executive summary. The press have printed a selection. For example, the Guardian published:[57]

• A law requiring owners and managers of high-rise residential buildings to provide their local fire and rescue service with information about external wall materials and building plans.
• Fire brigade inspections of high-rise buildings to be improved and crews trained to carry out more thorough risk evaluations. Regular inspections of lifts intended to be used by firefighters are needed.
• Communications between fire brigade control rooms, where emergency calls are received, and incident commanders must improve and there must be a dedicated communication link.
• Government should develop national guidelines for carrying out partial or total evacuations of high-rise residential buildings.
• Fire doors in all multi-occupancy, residential properties should be urgently inspected.
• Improvements should be made to the data links provided by helicopters of the National Police Air Service.[57]