Last edited 05 Sep 2024

The Grenfell phase 2 final report recommendations for the construction industry

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Contents

[edit] Recommended measures in general

The Terms of Reference of the inquiry included the recommendation of measures to be taken in response to any deficiencies found to exist in the matters under investigation. The inquiry grouped their recommendations by reference to the subject matter to which they relate, (113.1) that being under five headings:

[edit] Issues raised, at a glance

Here is a very brief look through some of the key issues discussed in the report (further details in sections below):

[edit] Guidance and governance

[edit] Projects and products

[edit] Professionals and purpose

[edit] Processes and practicality

[edit] Recommendations made, at a glance

Here is a very brief look through some of the key recommendations mentioned in the report (further details in sections below):

[edit] Guidance and governance

[edit] Projects and products

[edit] Professionals and purpose

[edit] Processes and practicality

[edit] Issues surrounding the construction industry in detail

This section covers in some depth the main points relating to the construction industry, as discussed in the report with references. Considering the severity of the event and significance of this report it is strongly recommended that the original report also be studied. All sections of the Phase 1 and Phase 2 reports of the Grenfell Inquiry can be found here.

[edit] Deficiency in four elements of the construction industry

The system of regulating the construction and refurbishment of high-rise residential buildings at the time was seriously defective. Approved Document B, poorly worded and liable to mislead designers to think complying with it ensures complying with the requirements of the Building Regulations. Government departments responsible for the Building Regulations failed actively to monitor the performance of the system, to ensure dangers it became aware of, were communicated to the industry and was not sensitive to making urgent changes statutory guidance as required. (113.2)

There is no reason to think other aspects of building safety are not subject to similar considerations. The safety of people in the built environment depends principally on a combination of three primary elements and dependent on a fourth:

  1. Good design
  2. The choice of suitable materials
  3. Sound methods of construction
  4. The skill, knowledge and experience of those engaged in the construction industry.

At the time of the Grenfell Tower fire investigations show serious deficiencies in all four of these areas. (113.3)

[edit] Fragmented regulatory arrangements

Regulatory arrangements for the construction industry are too complex and fragmented.

This degree of fragmentation was a recipe for inefficiency and an obstacle to effective regulation. (113.4)

[edit] Fragmentation reflected in government

Construction industry fragmentation is mirrored in the range of government departments responsible for matters affecting fire safety. If a single body were responsible for all aspects of regulating matters affecting fire safety in the construction industry, that body should report to a single Secretary of State. Providing an administrative environment where information can be shared more quickly and effectively between teams responsible for different aspects of the work and facilitate communication between the regulator and the department.

[edit] Interpretation of the guidance and relationship to legislation

Legal requirements of Regulations in terms of functional requirements not themself deemed unsatisfactory, but the way statutory guidance in Approved Document B was expressed is deemed unsatisfactory in a number of respects. Chapter 6; the retention of Class 0, as a standard governing the fire performance of external wall panels, Chapter 48; consequences of expressing in an apparently prescriptive form what is actually guidance. Thought that Approved Document B does not provide the information needed to design fire safe buildings. (113.10)

Investigations showed levels of competence generally low at the time and many contractors, designers and building control officers treated statutory guidance as a definitive statement of the legal requirements. Understandable that those who turn to the guidance for advice about how to comply with the Building Regulations are tempted to treat it as if it were definitive, but that is a danger that the Secretary of State needs to recognise and guard against. Recommend a revised version of the guidance contains a clear warning in each section that the legal requirements are contained in the Building Regulations and that compliance with the guidance will not necessarily result in compliance with them. (113.12)

[edit] Compartmentation, the 'stay-put' approach and calculations

It was deemed not appropriate to recommend specific changes to Approved Document B, but as pointed out in Chapter 48, the guidance proceeds on the assumption that effective compartmentation renders a stay put strategy an appropriate response to a fire in a flat in a high-rise residential building. New materials and methods of construction and the practice of over cladding existing buildings make the existence of effective compartmentation a questionable assumption and we recommend that it be reconsidered when Approved Document B is revised. Inquiry investigations have shown that in order to ensure the safety of occupants, including any with physical or mental impairments, those who design high-rise buildings need to be aware of the relationship between the rate at which fire is likely to spread through the external walls and the time required to evacuate the building or the relevant parts of it.

A stay put strategy in response to a compartment fire will be acceptable only if there is negligible risk of fire escaping into and spreading through the external wall. Calculating the likely rate of fire spread and the time required for evacuation, including the evacuation of those with physical or mental impairments, are matters for afire safety qualified fire engineer. It may not be helpful to attempt to include in Approved Document B an indication of what would be acceptable because each building is different, but the guidance might draw attention to the need to make a calculation, one that ought to be essential to the fire safety strategy. (113.13)

[edit] Fire performance testing methods and standards

Assessing the fire performance of an external wall requires reliable information about the products and materials proposed for use in its construction, which in turn requires the availability of suitable methods for testing reaction to fire. Small-scale test methods (see Chapter 111) do not provide information needed, large-scale test method (BS 8414) and classification in accordance with BR 135 lacks relevant performance criteria and provides a limited amount of useful information. (113.16)

Phase 2 inquiry experiment investigations, showed factors affecting the way fire spreads over ventilated rain screen external wall systems are complex, understanding them is an evolving science and small changes can have significant effect on outcomes. Thus assessing whether an external wall system can support a particular evacuation strategy is difficult because the necessary information is not always available. Recommended that steps be taken to develop new test methods that provide the information needed for such assessments to be carried out reliably. (113.17)

Based on evidence it is thought that BS 9414 will encourage people who are not trained fire engineers to think that they can safely assess the performance of a proposed external wall system by extrapolation from information obtained from tests on one or more different systems. Thus BS 9414 should be approached with caution, recommended that the government make clear it should not be a substitute for an assessment by a suitably qualified fire engineer. (113.18)

[edit] Issues with certification of products and publication of test data

In product literature manufacturers make many claims for products, some of which are not of an overtly technical nature but calculated to give the impression that a particular product has passed a particular test or has been shown to be suitable for a particular use. Such marketing devices were employed by those who manufactured and sold the rain screen cladding panels and the insulation used in the refurbishment of Grenfell Tower. Those responsible for designing buildings must have access to reliable information about the materials and products used. (113.19)

Manufacturers were able to use misleading marketing material in part because certification bodies that provided assurance to the market of the quality and characteristics of the products failed to ensure the statements in the certificates they issued were accurate and based on appropriate and relevant test evidence. The United Kingdom Assessment Service (UKAS), the organisation charged with accrediting them, failed to apply proper standards of monitoring and supervision. That three separate manufacturers were able to obtain misleading certificates relating to their products is evidence of a serious failure and need for a different approach to construction product certification. (113.20)

The inquiry does not think appointing the National Regulator of Construction Products will solve the problem because the system still depends on the effectiveness of the conformity assessment bodies and the limited oversight of UKAS. These bodies provide a commercial service combined with elements of regulation, the two functions do not sit easily together. Pressure to acquire and retain customers can lead to less rigour in examination of products and materials and enforcing terms of contracts than could reasonably be expected of bodies acting in the public interest. (113.21)

[edit] Issues in the meaning of the term and training of fire engineers

The term “fire engineer” does not at present denote formal qualification and as a result it is possible for a person to practise as a fire engineer without any formal qualification. Evidence suggests that not all those who profess to be fire engineers are capable of performing that role competently and that the complexity of the subject matter is not well understood. Designing buildings that are safe in the event of a fire requires particular skill, that can be acquired only by specialised education and experience worthy of formal recognition. (113.24)

Development and maintenance of a statement of professional skills should ultimately be the responsibility of the body that regulates the profession, but pending the establishment of such a body it is recommended that the government convene a group of practitioner and academic fire engineers and such other professionals as it thinks fit to produce an authoritative statement of the knowledge and skills to be expected of a competent fire engineer. This would also enable others to understand the nature and importance of a fire engineer’s work. It would be of benefit to those carrying out this work to have regard to the reports of the Warren Centre, referred to in Chapter 112. (113.27)

It is also recommend that the government, working in collaboration with industry and professional bodies, encourage the development of courses in the principles of fire engineering for construction professionals and members of the fire and rescue services as part of their continuing professional development. (113.28)

[edit] Basic understanding of fire principles for other construction professionals

Other construction professionals and more senior members of the fire and rescue services need to have a basic understanding of the principles of fire engineering as they apply to the built environment. The circumstances surrounding the Grenfell Tower fire show that an effective contribution from a fire engineer could have prevented the disaster by alerting the client and the principal contractor to the dangers of using aluminium composite panels with unmodified polyethylene cores and combustible insulation in the external wall of the building.

An authoritative statement of the skills that a fire engineer can be expected to bring to bear might assist the regulatory body and would improve the competence of other construction professionals and the fire and rescue services by enabling them to understand better the contribution that fire engineers can make to the construction of a safe building. It would also promote effective communication between them. Such a statement would need to draw on and reflect the experience of both practising fire engineers and those in the academic world to ensure that it was objective and properly reflected the scientific and intellectual demands of the role. (113.26)

[edit] Issues with the architectural profession

Traditionally, the role of the architect has been fundamental to any construction project of significant size. The work on the Grenfell Tower refurbishment fell significantly below the standard to be expected in a number of significant ways, in particular, failing to exercise proper care in relation to the choice of insulation and rain screen panels. The evidence, of similar materials since been found on hundreds of other high-rise buildings, suggests a widespread failure among the profession to investigate properly or understand the nature of the materials being chosen for that purpose. (113.29)

[edit] Issues with contractors

The design and build form of contract, now widely used, makes the principal contractor responsible for the whole range of activities relating to the work, even though invariably sub-contractors carry out different aspects of work. Failings on Grenfell included a failure to make clear which contractor was responsible for particular aspects of the design and a failure to take an active interest in fire safety. We are not the first to conclude that the construction industry as a whole needs to become technically more competent and less willing to sacrifice quality to speed and cost. (113.32)

[edit] The role of the client

The events surrounding the refurbishment of Grenfell Tower suggest that at that time those who commissioned building work may not have been fully aware of their responsibility for compliance with the provisions of the Building Regulations, particularly if an application for building control approval was made by a consultant on their behalf. The introduction by regulations made under the Building Safety Act 2022 are welcomed, in particular the requirement for a compliance statement, made or approved by the client, to be provided at the time of an application for building control approval (Gateway 2). In the light of that requirement no further action in relation to clients is currently required. (113.34)

[edit] The role of building control

Evidence shows leading up to the Grenfell Tower fire many involved in major construction projects, including clients, contractors and even architects, regarded building control primarily as a source of advice and assistance. Even described as an extension of the design team. In many cases that was how building control itself saw its role. That is a serious misunderstanding, but one fostered by building control bodies, who preferred to co-operate with applicants to enable proposals to be approved rather than enforce the Building Regulations rigorously. In our view, that has to change. (113.35)

Steps to improve the regulation of building control and the competence of those who consider applications for approval have been taken. Expect is the construction regulator will continue these new arrangements, intended to introduce a new climate in which applicants for approval and building control officers understand that the function of building control is regulatory in nature. (113.36)

One of the causes of the inappropriate relationship to which we have referred was the introduction into the system of commercial interests. Approved inspectors had a commercial interest in acquiring and retaining customers that conflicted with the performance of their role as guardians of the public interest. Competition for work between approved inspectors and local authority building control departments introduced a similar conflict of interest affecting them. As things stand that underlying conflict of interest will continue to exist and will continue to threaten the integrity of the system. It is therefore recommended that the government appoint an independent panel to consider whether it is in the public interest for building control functions to be performed by those who have a commercial interest in the process. (113.37)

The shortcomings identified in local authority building control suggest that in the interests of professionalism and consistency of service all building control functions, including those currently performed by local authorities, should be exercised nationally. Accordingly, it is recommend that the same panel consider whether all building control functions should be performed by a national authority. (113.38)

[edit] Fire control switches in lifts

All modern lifts are fitted with fire control switches designed to be operated by drop keys to enable the fire and rescue services to take control of them in the event of a fire. We were surprised to learn that at the time of the Grenfell Tower fire there was a significant variation in the dimensions of drop keys available from commercial suppliers, not all of which were compatible with all fire control switches. We were also surprised to learn that, although drop keys for the use of firefighters are provided by fire and rescue services, firefighters commonly obtain their own from a variety of sources. As a result, it appears to have been largely a matter of chance whether the key carried by the first firefighter who tried to take control of a lift was capable of operating the switch. That is clearly unacceptable and may result in unnecessary casualties, as it did at Grenfell Tower. (113.42)

We understand that since the problem came to light the LFB has taken steps to ensure that only drop keys of an approved pattern are carried by its firefighters. The evidence does not enable us to assess with any confidence whether similar problems have been encountered by other fire and rescue services and, if so, what steps they have taken in response. Accordingly, we are not in a position to determine whether greater standardisation of fire control switches and keys is required. We therefore recommend that the government seeks urgent advice from the Building Safety Regulator and the National Fire Chiefs Council on the nature and scale of the problem and the appropriate response to it. (113.43)

[edit] Pipeline isolation valves

Pipeline isolation valves are a critical part of the gas distribution network, intended to enable supply of gas to be shut off quickly in an emergency. At Grenfell Tower the valves could not be operated because they had been covered over in the course of hard landscaping, evidence is that it was a common problem for pipeline isolation valves to be lost in that way. This poses an unacceptable risk to health and safety and could have significant consequences. Recommend every gas transporter be required by law to check the accessibility of each such valveat least once every three years and to report the results of that inspection to the Health and Safety Executive as part of its gas safety case review. (113.44)

[edit] Ageing pipework

One of the expert witnesses, drew attention to the danger posed by the fact that the internal gas pipework in some older buildings is not sleeved where it passes through walls and floors, as is now required by the Gas Safety Regulations 1972. He considers that a more active approach to replacement should be taken to avoid a serious leak with potentially catastrophic consequences. Though not in a position to make a formal recommendation to that effect, the Health and Safety Executive and other relevant bodies should give careful consideration to his evidence. (113.45)

[edit] Recommendations for the construction industry

This section covers in some depth the main recommendations relating to the construction industry, as discussed in the report with references. Considering the severity of the event and significance of this report it is strongly recommended that the original report also be studied. All sections of the Phase 1 and Phase 2 reports of the Grenfell Inquiry can be found here.

[edit] Recommended single regulator and point of contact

All the functions above, as well some others, should be exercised by a single independent body headed by a person ( for example called a 'construction regulator') reporting to a single Secretary of State. This would bring benefits, a focal point driving change in the culture of the construction industry, enable information to be shared effectively between those in the industry, promote the exchange of ideas, developments in the industry, here and abroad. Such a construction regulator would have resources to take on the following functions, currently discharged by one or other of a variety of bodies:

Since the Grenfell Tower fire Parliament has passed the Building Safety Act 2022 to regulate work on higher-risk buildings, to impose particular duties on those involved in the construction and refurbishment of such buildings and to establish a Building Safety Regulator responsible for building control and for overseeing standards of competence. However, responsibility for the range of functions identified above remains dispersed, it is recommend the government draw together under a single regulator all the functions referred to relating to the construction industry (113.6)

[edit] Recommended review the definition of 'higher-risk'

The expression “higher-risk building” used as in the Building Safety Act, ie a building at least 18 metres in height (or has at least seven storeys) and contains at least two residential units. However, defining a building as “higher- risk” by reference only to its height is unsatisfactory and arbitrary in nature. More relevant is the nature of use, in particular, the presence of vulnerable people, for whom evacuation in an emergency presents difficulty. It is therefore recommend that the definition of a higher-risk building for the purposes of the Building Safety Act be reviewed urgently. (113.7)

[edit] Recommendation of Chief Construction Adviser

Recommend that the government bring responsibility for the functions relating to fire safety currently exercised by MHCLG, the Home Office and the Department for Business and Trade into one department under a single Secretary of State. (113.8) Recommend Secretary of State appoints a Chief Construction Adviser with good working knowledge and practical experience of the construction industry, and a sufficient budget and staff to provide advice on all matters affecting the construction industry, including:

[edit] Recommend Approved Document B, Regulations and statutory guidance review

Recommend a revised version of the guidance contains a clear warning in each section that the legal requirements are contained in the Building Regulations and that compliance with the guidance will not necessarily result in compliance with them. (113.12)

Approved Document B needs to be reviewed as a matter of urgency, taking into account expert evidence from the inquiry. It must then be kept under continuous review, together with the other Approved Documents, and amended annually or promptly with developments in materials or building methods. Drafted conservatively to ensure, as much as possible, compliance with it gives high degree of confidence that the building will comply with the Building Regulations. Recommended that the statutory guidance generally, and Approved Document B in particular, be reviewed accordingly and a revised version published as soon as possible. (113.11)

Recommended a fresh approach taken to reviewing and revising the Building Regulations and statutory guidance, driven primarily by considerations of safety. Fresh minds are needed and recommend membership of bodies advising on changes to statutory guidance should include academic community as well as those with practical experience of the industry (including fire engineers), should extend beyond those who have served on similar bodies in the past. (113.14)

[edit] Recommended building control fire safety strategy requirement and potential calculations

A fire safety strategy should outline the structure and fire protection systems of a building, how they work together to ensure occupant safety. The Grenfell Tower team failed to understand the need for a fire safety strategy, failing to ensure a final version of the Outline Fire Safety Strategy was completed, leaving the building in a dangerous condition. To avoid a repeat of that error, there is a compelling case to require a fire safety strategy as a condition of building control approval for construction or refurbishment of higher-risk buildings, to be reviewed and approved on completion. Recommend it be made a statutory requirement that a fire safety strategy produced by a registered fire engineer to be submitted with building control applications (at Gateway 2) for the construction or refurbishment of any higher-risk building to be reviewed and re-submitted at the stage of completion (Gateway 3). It must take into account needs of vulnerable people, including additional time required to reach a place of safety within it and additional facilities to ensure their safety. (113.15)

Calculating the likely rate of fire spread and the time required for evacuation, including the evacuation of those with physical or mental impairments, are matters for afire safety qualified fire engineer. It may not be helpful to attempt to include in Approved Document B an indication of what would be acceptable because each building is different, but the guidance might draw attention to the need to make a calculation, one that ought to be essential to the fire safety strategy. (113.13)

[edit] Recommendation for test methods, certification of products, publication of test data and construction regulator product conformity

Recommended that steps be taken to develop new test methods that provide the information needed for such assessments to be carried out reliably. (113.17)

Recommend that the construction regulator should be responsible for assessing the conformity of construction products with the requirements of legislation, statutory guidance and industry standards and issuing certificates as appropriate. We should expect such certificates to become pre-eminent in the market. (113.22)

The inquiry sees clarity is required to avoid those who rely on certificates of conformity being misled and thus recommend

[edit] Recommended formalisation of term and training of fire engineers

Given the importance of fire engineers in ensuring the safety of life, the profession of fire engineer should be formally recognised and that both title and function should be protected by statute. Over time creating a body of registered fire engineers, capable of contributing to the design and delivery of safe buildings and educating construction professionals in effective fire safety strategies.

Recommendation is the profession of fire engineer be recognised and protected by law, an independent body established to regulate the profession, define the standards for membership, maintain a register of members and regulate conduct. To speed this up it is recommend the government take urgent steps to increase places on high-quality masters level courses in fire engineering accredited by the professional regulator. (113.25)

Pending the establishment of such a body it is recommended that the government convene a group of practitioner and academic fire engineers and such other professionals as it thinks fit to produce an authoritative statement of the knowledge and skills to be expected of a competent fire engineer. (113.27)

It is also recommend that the government, working in collaboration with industry and professional bodies, encourage the development of courses in the principles of fire engineering for construction professionals and members of the fire and rescue services as part of their continuing professional development. (113.28)

[edit] Recommendations for Architects

It is recognised that the ARB and the RIBA have taken steps since the Grenfell Tower fire to improve the education and training of architects. These changes should be reviewed to ensure they are sufficient in the light of this report. (113.30)

Recommendation is that it be made a statutory requirement that an application for building control approval in relation to the construction or refurbishment of a higher-risk building (Gateway 2) be supported by a statement from a senior manager of the principal designer under the Building Safety Act 2022 that all reasonable steps have been taken to ensure that on completion the building as designed will be as safe as is required by the Building Regulations.(113.31)

[edit] Recommendations for Contractors

We think that one way in which to eliminate shortcomings of the kind we have identified and to improve the efficiency of contractors would be to introduce a licensing system for those wishing to undertake work on higher-risk buildings. That would ensure that those working on the most sensitive buildings are qualified by experience and organisation to do so and such a system should lead to a general increase in competence among contractors.

We also think that, in order to ensure that fire safety is given the importance it deserves, a senior member of the contractor’s organisation should be personally responsible for taking all reasonable steps to ensure that on completion of the work the building is as safe as it should be. We therefore recommend that a licensing scheme operated by the construction regulator be introduced for principal contractors wishing to undertake the construction or refurbishment of higher-risk buildings and that it be a legal requirement that any application for building control approval for the construction or refurbishment of a higher-risk building (Gateway 2) be supported by a personal undertaking from a director or senior manager of the principal contractor to take all reasonable care to ensure that on completion and handover the building is as safe as is required by the Building Regulations. (113.33)

[edit] Recommendations for Building control

It is recommended that the government appoint an independent panel to consider whether it is in the public interest for building control functions to be performed by those who have a commercial interest in the process. (113.37)

The shortcomings identified in local authority building control suggest that in the interests of professionalism and consistency of service all building control functions, including those currently performed by local authorities, should be exercised nationally. Accordingly, it is recommend that the same panel consider whether all building control functions should be performed by a national authority. (113.38)

[edit] Recommendation for a construction library

Those who design buildings, particularly higher-risk and complex buildings, would benefit from having access to a body of information, such as data from tests on products and materials, reports on serious fires and academic papers. In Chapter 112 the inquiry referred to the Cladding Materials Library set up by the University of Queensland, which could form the basis of a valuable source of information for designers of buildings in general. It is recommend that the construction regulator sponsor the development of a similar library, perhaps as part of a joint project with the University of Queensland, to provide a continuing resource for designers. (113.39)

[edit] Responding to recommendations

Investigations revealed that some important recommendations affecting fire safety were ignored by the government in the years leading up to the Grenfell Tower fire. Recommendations made by the Select Committee in 1999 were not implemented and the department’s response to the recommendations made by the Lakanal House coroner was inadequate. The department had no system for recording recommendations made by public bodies or keeping track of its response to them. That was obviously unsatisfactory. It is recommend that it be made a legal requirement for the government to maintain a publicly accessible record of recommendations made by select committees, coroners and public inquiries together with a description of the steps taken in response. If the government decides not to accept a recommendation, it should record its reasons for doing so. Scrutiny of its actions should be a matter for Parliament, to which it should be required to report annually. (113.40)

[edit] Recommendations for fire risk assessors

As pointed out in Chapter 12, concern has been expressed for many years about the competence of some of those offering their services as commercial fire risk assessors and the absence of any scheme of regulation to ensure that responsible persons under the Fire Safety Order can have confidence in the skill and experience of those whom they instruct to carry out fire risk assessments on their behalf. It is recommend that the government establish a system of mandatory accreditation to certify the competence of fire risk assessors by setting standards for qualification and continuing professional development and such other measures as may be considered necessary or desirable. It is necessary for an accreditation system to be mandatory in order to ensure the competence of all those who offer their services as fire risk assessors. (113.41)


This article is based on 'Publication of the Grenfell Tower Inquiry phase 2 report' The Panel: Chairman: The Rt Hon Sir Martin Moore-Bick, Ali Akbor OBE, Thouria Istephan dated September 2024

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