What The Grenfell Tower Inferno Tells Us
about deregulation, accountability and the mosaic of institutional failure
The first big storm of the season rolled in over the Great Dividing Range early one afternoon last week. Even without the official forecast you knew from morning that it was on the way. The air coiled around itself like a compressed spring. In possession of a large enough spoon, one could ladle the moisture directly into a bowl.
It’s the transgressive physicality of storms I love most. In ordinary repose, the elements are familiar to us and stick, more or less, to their allotted lane. The air might stir on the skin but it does not otherwise transmute. We find water where it ought to be and the sky itself retains its heavenly proportions. As a storm builds, however, these categorical features of the environment tend to become more expressive; not for them the boundary of expectation.
All that potential energy begins to stir. A person can hear the mains hum of atmosphere. And then rain, fat as treacle. And then hail, clattering against concrete on a day when it felt earlier as if the pulsing heat could melt the whites of your eyes. Wind, lightning; all of it sprung from the convective happenstance of a normal, still day.
Storms are cyclical, of course, but whether or not any particular one forms on any particular day is the result of a tango between hot and cold air, the local topography and, if you believe the Marjorie Taylor Greenes of the world, the United States government.
Greene, who doesn’t believe in anthropogenic climate change — a process that took almost 200 years of sustained, devastating and global industrial output — nevertheless asserts that ‘they’ can control the weather, without exactly elaborating on who she means by ‘they’. Likely it serves as a rorschach test for the intended audience, but the implication this time around as hurricanes one-two punch Florida seems to be that the Democrats are behind it. Any government with that kind of capability would rule for a thousand years.
Weather is famously complicated and any farmer will tell you it bends to the whim of no one. It’s also not magic. A brooding storm might seem a kind of alchemy, but it still obeys the laws of physics. Arranged in the right way, trillions and trillions of molecules will give rise to a storm from apparently nothing. In this respect, at least, such an event seems greater than the sum of its parts.
The amount of sheer effort it takes to believe a conspiracy of weather control-by-government when governments everywhere — especially in the land of the corporate free — have degraded themselves willingly over decades is almost impressive. A Marjorie Taylor Greene (MTG) type will confidently declare a plot to bombard Florida, the Queensland of the northern hemisphere, with hurricanes but baulk at even the faintest suggestion indiscriminate deregulation might similarly be killing people as its thousands of tiny molecules arrange themselves for the storm.
One of these things isn’t a conspiracy.
Complexity Is Not Magic
On 14 June 2017, an electrical fault in a fourth floor refrigerator started a fire which escaped an apartment in the 24-storey Grenfell Tower in London and met the newly refurbished outer ‘skin’ of the building made from cladding its manufacturer Arconic knew for certain a decade earlier ‘would be equivalent to attaching a 19,000-litre oil tanker to the outside of the building’. As James Butler wrote in the London Review of Books this month:
The potentially lethal consequences were perfectly clear to Arconic’s senior management. ‘What will happen if only one building made out [of] PE core is on fire and will kill sixty to seventy persons,’ one manager asked in an internal memo, ‘what is the responsibility of the ACM [aluminium composite panel] supplier?’
Well, 72 people died because of the Grenfell Tower inferno.
A seven-year inquiry into its causes — and God, there were a constellation of deceptions, failures and cover-ups that led to that moment — reported for the second time last month. The document, which I have been trying to read for most of the weekend, achieves what has become so difficult in the post Thatcher landscape in the West: it methodically sets out the case for murder by privatisation where public goods such as housing and fire safety construction standards are either outsourced or beholden to the greed of corporate interests and ‘overseen’ by emaciated or even complicit state institutions.
To even raise this in modern times has been to court ridicule. It does not take much in the way of imagination to draw a line from lax safety standards to the deaths of people but, unfortunately, the deregulation boosters have always suffered from a lack of imagination. They certainly don’t have much to say about the interior lives of the very people, like those residents of Grenfell Tower, who had the most to gain from a system that actually saw them as human beings for a start and, further, that recognised they might not wish to suffocate surrounded by toxic smoke in their council flats.
The diorama of blame at Grenfell is extraordinary and self-reinforcing. Take, for example, the Building Research Establishment (BRE) a formerly in-house government fire safety lab that was privatised in 1997 and continued to conduct its product tests for commercial clients while reporting results back to government departments. The report says:
One very significant reason why Grenfell Tower came to be clad in combustible materials was systematic dishonesty on the part of those who made and sold the rainscreen cladding panels and insulation products. They engaged in deliberate and sustained strategies to manipulate the testing processes, misrepresent test data and mislead the market. In the case of the principal insulation product used on Grenfell Tower, Celotex RS5000, the Building Research Establishment (BRE) was complicit in that strategy.
BRE allowed the insulation manufacturer to design its test of the Celotex RS5000 with the inclusion of fire retardant magnesium-oxide boards in ‘critical positions’ that helped it pass the assessment. BRE then deliberately omitted any reference to these critical boards in its report on the test. Over and over again, we are presented with evidence of this type.
The Aluminium Composite Panels (ACM) made by Arconic that were used in the rainscreen cladding on Grenfell were used in a so-called ‘cassette’ form, like a Maxibon ice cream sandwich. Aluminium panel, exceptionally combustible polyethylene core, aluminium panel. Bingo, cassette. In a large-scale test conducted by BRE of this type of cladding all the way back in 2002, the configuration became so hot so fast that it had to be abandoned; investigators could see molten aluminium dripping from the rig after just three minutes. The flames reached 20m in height after five.
Remarkably, this product still met the Class-0 fire safety standard in force at the time for the spread of fire across its surface and BRE’s report back to government only noted that other products performed better and that some ‘further consideration’ was required in relation to it. The opinion of the testers that the product with an unmodified polyethylene core should never be used on tall buildings was never included. The Department received the report and the results were never made public.
Never made public.
A lab is a lab, of course, and the real world can introduce genre-defining complexity. So, in 2005, when ACM panels ‘de-laminated’ and peeled away during a fire at a block of flats in Greater Manchester, exposing the highly flammable polyethylene core, the results were in. The fire exploded from a second floor balcony and reached the top of the 19-storey building in 10 minutes.
BRE were assigned to investigate.
BRE’s second report into the fire dated 31 March 2005 warned that even if the construction had complied with current guidance, that would not have restricted the speed at which the fire had spread through it. It also reported that the fire and rescue services had grave concerns that a fire of that nature could quickly get out of control and put the lives of occupants at risk.
There were hundreds of fires ‘investigated’ by BRE between 2001 and 2015 — typically they had 15 minutes per fire and often just cribbed notes from news reports — and always included a standard paragraph in the annual summary that indicated ‘the overall effectiveness of the building regulations and ADB [Approved Document B] in providing for the safety of life in the event of fire and most of the significant issues that have been identified during this study fall outside the scope of these regulations’.
This just couldn’t have been true in relation to some of the fires they knew about, like the cladding fire in Greater Manchester detailed above, and certainly wasn’t true of the other incidents where the exact type of ACM products were involved in the spread of flames but which investigators never picked up because they couldn’t do their jobs properly. Later, the government department even forbid them from making policy recommendations which seemed engineered to avoid any persnickety suggestions that might require them to do their jobs.
That shift in approach was entirely consistent with the evidence we heard from senior civil servants in the Department who explained to us the pressures they were under at the time due to the government’s overarching desire to deregulate.
In 2009, at a 12-storey block of flats in London known as Lakanal House, a faulty TV sparked a fire that raced through exterior cladding and killed six people, injuring 20. The public servant in charge of building construction regulations in the UK department, Brian Martin (he’d been in the job for 17 years by the time of the Grenfell tragedy) admitted that they weren’t really worried about what this fire meant for high rise buildings already fitted with deadly cladding and fretted, only mildly, about whether the regulations needed to be updated. In any event, none of the cladding panels on the Lakanal House block actually met existing standards and this was taken as evidence that the issues there were specific and not country-wide.
‘Mr Martin’s explanation was that the department had been concentrating on improving building standards for the future and did not consider examining the effect of previous standards to be part of its function.1018 In our view that was not a responsible approach to take to a fire in which six people had died,’ the inquiry found.
A coronial inquest into those deaths was held and Martin, among others, gave misleading evidence about what he and they knew then about the significant and emerging evidence that composite cladding was a potential death trap. Martin didn’t even think to mention it. A coronial jury returned verdicts that should have sent chills down the institutional spine of those charged with monitoring regulations. Instead, they were ignored.
Those findings should have been a warning to the department that building professionals were not aware of, or were misinterpreting or ignoring, Approved Document B. They should also have served as a warning that the effectiveness of the Building Regulations and Approved Document B to protect life were in question. The department ought to have undertaken further investigations to find out whether the use of unsafe panels in the external wall of Lakanal House was an isolated incident or had been due to systemic ignorance or misunderstanding of the Regulations and Approved Document B. However, the department failed to undertake any such investigation.
Martin was downright dismissive of the Coroner’s recommendations. They didn’t need to ‘kiss her backside’ he said. In writing.
As it stands, the Department never properly responded to them. A go-slow approach eventually turned into… why bother?
Subsequent matters that kept referring back to broad promises to review the building regulations following the deadly Lakanal House fire met with outright antagonism from the department, especially Brian Martin. Even the parliamentary group pushing for better safety standards was derided and mocked. Here Martin is talking about Ronnie King, the chair of the All-Party Parliamentary Group on Fire Safety and the ‘AD’ refers to the Approved Document from the building regulations which forms the standards with which industry must comply.
‘I just ignore him’.
Two-and-a-half years later, Grenfell happened. And this isn’t some exercise in hero-making. The parliamentary group weren’t just being annoying. They were extremely well-informed, as it happened, and oracle-like.
Throughout the correspondence some of the concerns raised by the Group displayed a prescience about what was later to occur at Grenfell Tower. They included the danger posed by the use of Class 0 as the sole criterion of suitability for external wall coverings, research that showed that Approved Document B was out of date, aspects of the guidance in Approved Document B that required immediate attention, significant consequences for the safety of life if Approved Document B were not reviewed more quickly, the increased use of combustible material, the risk to life caused by the use of combustible materials, the dangers created by the use of modern materials and methods of construction, and the need to review Approved Document B in a timely manner.
As for Martin’s claim that they’d review the Approved Document B when they were good and ready, the Grenfell Inquiry simply noted: ‘The department never did do it and was never ready. Its failure was profound’.
Around this same time, Martin became increasingly aware of terrifying building fires in the UAE, France and Melbourne, Australia.
These stirred nothing in him.
Deregulation, Baby
When David Cameron became Prime Minister of the United Kingdom in 2010 he did exactly what Tony Abbott would do here only three years later: issue a decree that unnecessary red tape and regulation should be chopped and that any new rule must be accompanied by an offset, a so-called ‘one in, one out’ principle. The rationale was the same as it ever was, as the Grenfell inquiry summed it up: ‘That national productivity and economic growth were being held back by unnecessary regulation which needed to be swept away’.
One in, one out soon became one in, two out and then three out.
I spend some time in my new book Mean Streak exploring the explicit link between Tony Abbott’s deregulation agenda and the actual genesis of Robodebt. Those who crafted the policy particulars before it was even sniffed at by a secretary or minister had figured that they could piggy-back on the red tape reduction obsession of the new government to push through its fatal compliance overhaul.
The red tape they were reducing, by the way, was from business — especially small business — while simultaneously increasing the burden hideously on people suspected of welfare non-compliance using their dodgy method of income averaging tax office data into 26 Centrelink fortnights, which the Department of Human Services knew produced inaccurate income earning patterns. Despite this, as I show in Mean Streak, the bureaucrats asserted that all 866,000 people envisioned to be targeted in the first stage of the program were ‘definitely’ non-compliant.
Suddenly, for the purposes of care, safety and decency these people simply ceased to exist.
Robodebt’s early project branch manager was Scott Britton and he freely told anyone who would listen that they needed to ‘leverage’ deregulation to get their compliance wishlist through government because it needed policy change, and maybe some upfront investment, and this was the way to sell it. Taking the heat off business and putting it on past and former welfare recipients was an acceptable strategy because, frankly, very few people cared about people on welfare. It was a national sport, hating them. It is a national sport.
The similarities with Grenfell, even down to the time periods in question, are hard to ignore. Former Secretary of State for Communities and Local Government Eric Pickles — now Lord Pickles, thank you very much — was a particularly enthusiastic sponsor of his government’s one-in, however-many-out anti-rules rule. At one point during his tenure he even wrote to the Welsh Government getting shirty at them for daring to mandate fire sprinklers on new and newly converted homes ‘on the basis that it was increasing the cumulative burden of regulation on the housing market in Wales’.
Now, Pickles gave evidence at the inquiry that he was mortified to think anyone in his department would have thought the government was serious about deregulation which was… swiftly rejected by the inquiry chair.
While he was Secretary of State deregulatory considerations appear to have permeated every aspect of the department’s development, assessment and implementation of policy. Far from its being inexplicable that officials were under the impression that the Building Regulations and Approved Document B were subject to the various demands of the policy, the documents demonstrated in clear terms that their understanding was correct… We have been unable to accept his evidence on that question, which was flatly contradicted by that of his officials and by the contemporaneous documents. Moreover, in its written closing statement the department accepted that the policy on deregulation being promoted across government since 2010 created an environment in which officials working on Building Regulations felt unable to propose regulatory interventions or refer their concerns to more senior managers. It is a matter of serious concern that officials in the Building Regulations and Standards Division were so affected by the deregulation policy that they were inhibited from giving candid and clear advice to ministers on the implications of not taking certain regulatory steps.
I remember early on in the Robodebt Royal Commission hearings, one of the Commonwealth’s counsel, Tim Begbie KC, was making submissions about whether the Commissioner Catherine Holmes should overturn the inherent Public Interest Immunity (PII) that attaches to Cabinet documents. The Commonwealth position was an exercise in totality. It argued that even documents that were not themselves Cabinet in confidence might provide a clue as to the contents of other documents that were secret, even if on their own the clues could not be pieced together and only accrued any meaning at all when examined against other similar documents and so on and so forth. Begbie:
You have no doubt seen in other public interest immunity claims, national security and so forth, it's sometimes referred to as mosaic analysis, but the idea you can take different - that are not the subject of any claim - and put it all together and therefore draw reliable inferences so that even a piece of information in a preparatory cabinet document, read alone you might look at and say, "What is the problem here?" But the question is what does it amount to in the context of what is publicly known.
Mosaic analysis. Perhaps not for the reasons Begbie intended, I was immediately taken with the clarity of the phrase. That is what we were doing, I thought. With any inquiry, of course, but especially the ones where we are trying to figure out how the fuck a storm formed from a calm spring day.
A mosaic is emergence as art; a piece greater than the sum of its parts. Administrative failures like Grenfell, or the hybrid conspiracy-ineptitude of Robodebt, do not tend to happen because of a single ‘point of failure’ — despite Brian Martin in the UK department describing himself as one.
They happen, unfortunately, because a cast of dozens or hundreds or even thousands simply do not wish to do their jobs properly, cut corners or otherwise engage in behaviour that is at odds with their positions. In cases of tragedies like Grenfell, where the worst behaviour is reserved for the corporations who actively lied and marketed products they knew were building-sized fuel rods for an inferno, it does not exculpate the behaviour of the government types who were lazy or credulous or dismissive and contemptuous.
Not at all. It makes those civil mistakes all the more potent.
You can trace the lineage of the tragedy from the myopic politicians to fatally inattentive bureaucrats, on to the orbit of formerly public bodies like the BRE and the British Board of Agrément (which issues construction industry approvals certificates in the UK) which were all found to have been incompetent, reckless or complicit at times with the industry they were supposed to oversight and, finally, on to that private industry itself; the architects, the builders, the manufacturers of polyethylene sandwich panels and insulation products.
Just look at how real fire safety concerns eventually became extremely alarming for some at the privatised BRE: it wasn’t because people’s lives were at risk. When a university outfit suggested holding a meeting to discuss the increasing number of questions they were getting from industry — especially about the suitability of ACM panels and using combustible insulation in building rainscreens — BRE’s Dr Debbie Smith was immediately concerned they were trying to usurp their business.
The fire safety mantle indeed.
Isn’t It Arconic
The French company that made the composite polyethylene panels used for the rainscreen on the outside of Grenfell Tower knew very well that it did not pass fire safety tests — even rigorous ones done in France — for two reasons. One, the riveted form of the product passed because the sales boss Claude Wehrle told colleagues Arconic had ‘arranged’ for it to pass and second, the cassette form of the product, ultimately fitted on Grenfell, burned so fiercely the test was abandoned after 850 seconds.
It treated this latter test as a ‘rogue’ result but never tested the cassette form of the product again. Instead, it continued selling it with misleading statements that it had achieved certification. The Grenfell fire wouldn’t happen for another 12 years.
Arconic did not disclose the results of Test 5B to any testing organisation, certification body or end user in the UK at any time before the Grenfell Tower fire. Mr [Claude] Schmidt accepted that if the fire had not taken place it was likely that they would have remained secret.
By the time Arconic realised it needed UK certificates from the BBA in order to exploit a massive and growing market across the channel, the company also knew it couldn’t allow the cassette form of its cladding to be tested. Arconic worked to convince the BBA that the cladding should be tested only in the material form in which it left the factory and not in its final, fitted form that would attach to a building. The BBA knew, or should have known, that this could have a significant effect on the fire performance of a product but allowed it anyway.
Reynobond 55 PE was given the greenlight in England and Wales.
The reality is that Mr [Claude] Wehrle withheld Test 5B from the BBA, despite its obvious importance both to the BBA and to the UK market, because it showed that the fire performance of the product when used in cassette form was very significantly worse than when used in the riveted form covered by Test 5A.
Wehrle used an arcane French law, known as the French Blocking Statute, to avoid giving evidence in person at the Grenfell Tower Inquiry despite an opinion of the French Attorney-General that the statute did not or could not apply to Arconic or its employees. Accountability is always such a slender thing.
If Mr Wehrle had given evidence in person he would have had an opportunity to respond to the suggestion that he deliberately and dishonestly misled the BBA into thinking that Arconic held no results of any test of the product in cassette form. As it is, we have not had the benefit of hearing his response. Nonetheless, the evidence we have seen, which includes his statement, leaves us in no doubt that that is what he did. Our conclusion is reinforced by the fact that in none of its lengthy written or oral statements to the Inquiry did Arconic seek to suggest otherwise.
It’s worth noting here that Arconic sold a fire retardant version of the ACM panel core, Reynobond 55 FR, but this was more expensive to manufacture and the polyethylene core (PE) product was therefore a cheaper option for budget conscious (ahem) developers. Still, in 2007, Arconic reps attended a conference in which the deadly nature of the cheap system was on full display.
Marketing Manager Gerard Sonntag reported back to Arconic that the speaker, Fred-Roderick Pohl had warned ‘explained the extreme danger presented by the use of ACM PE on residential buildings, comparing the combustibility of 5,000m2 of ACM PE to that of a truck containing 19,000 litres of oil, and drawing attention to the fact that even greater danger was posed by the toxic smoke emitted by burning polyethylene, which could kill in two or three minutes’. Pohl was linked to another manufacturing company, but his hypothetical question alarmed Sonntag.
What would happen if ‘one building made out [of] PE core is in [a] fire and will kill 60 to 70 persons, what is the responsibility of the ACM supplier’?
Sonntag was so spooked by the presentation he started looking into the financial implications of Arconic only selling the fire retardant version of its panel, and trying to get the manufacturing cost down so it could still be sold at the PE price. They tried, but the price never fell far enough for the FR version to truly compete with the deadly PE one.
We think it is clear that by late 2007 Arconic had become aware that there was serious concern within the industry about the safety in fire of ACM panels with an unmodified polyethylene core (ACM PE) and had itself recognised the danger they posed. However, there is no evidence that Arconic took any steps to withdraw the sale of that product in the UK in the months and years that followed. On the contrary, not only did it continue to manufacture and sell ACM PE, it also sought to exploit what it perceived to be a weak regulatory regime in the UK while withholding from the market relevant information about the product’s fire performance. That contrasts with the position in other countries, such as France, where, in 2016, Arconic insisted that its sales team specify only Reynobond 55 FR.
In other email correspondence obtained by the inquiry, Wehrle makes repeated references to the fact that inconvenient facts about the cladding are ‘VERY CONFIDENTIAL!!!’ and that Arconic is ‘not clean’. In at least one exchange he outright lies to a customer in order to sell the damned thing. Wehrle explained to an incredulous colleague that there were ‘gaps in certification’ they ‘continued to make use of’.
Technicians elsewhere became confused, and alarmed. In this email to Wehrle, one literally points out that the cassette form of the cladding now has a European classification of ‘E’ which is basically spontaneous combustion.
We see a similar story with Kingspan, the maker of some of the Grenfell insulation product that had been — according to its sales people — ‘pigeonholed’ with combustible foam. Which is a bit like complaining your pigeon has been sat with the other pigeons. By their own admission, it didn’t pass fire safety tests for buildings above 18m. But on and on we go.
In the mosaic of failure, incompetence and greed that formed the Grenfell Tower tragedy — as it did Robodebt — we see how an individual who does not want to or cannot do their job properly enmeshes in a system of a thousand other such individuals who are apt, in isolation and then as whole institutions, to be duped, used or otherwise captured by private interests and corporations. Those latter interests care little for what they should do and are occupied, instead, with what they can get away with.
You see it with every regulatory system ever in existence. These interests are like water; they find their level.
Something that interests me in stories like these is the locus of blame. It is easy, as I have done here, to draw attention to the most egregious examples of disdain and mongrel. Those individuals deserve their place in the hall of infamy, of course, but the harder truth is the one that necessarily calls forth from the mosaic; those easily categorised individuals who have done clear or apparent ill are not so nearly effective on their own. They are enabled, to varying degrees, by the rest of us.
As a storm emerges from the static of a warm day, so too does a Grenfell or a Robodebt.
Very few see the significance of their patch until they have it arranged by circumstance with a thousand others into the worst of patterns.
Observations
So, so briefly as this has taken me days to write — and should, really, have taken me weeks but I am impatient and only got the idea on Friday — but my sister and my nephew arrived yesterday to attend the book launch tonight in Brisbane. THRILLED.
I’m off on book tour shortly, and have listed events here in previous newsletters but, in short, I’ll be doing events in Tathra on Friday night opening the Headland Writers’ Festival, Queenscliffe Literary Festival at the weekend, The Sun Bookshop in Melbourne on Monday night 21 October with Jactina Parsons, Gleebooks with David Marr on Wednesday 23 October in Sydney, Stanton Library in North Sydney on the Thursday 24 October (during the day) and then Canberra Writers’ Festival on Saturday and Sunday 27 October.
And, of course, for any one at a loose end tonight I’ll be launching Mean Streak with the incomparable Ellen Fanning at Souths League Club in West End Brisbane (120 Jane Street, on Davies Park). The wonderful people at Avid Reader are hosting the night and it’s going to be pretty special I think.
God this is so horrifying. I don’t know how you manage to keep writing about it. So many warnings are just ignored.
So happy you have family (and the gorgeous boy) with you for the launch - I'll read it with interest. A couple of random off-the-cuff comments on this fabulous piece (it deserves far more, but I'm pressed). "Persnikety" (great word) or "not a team-player" is always applied to any/all naysayers (I'm thinking here of RoboDebt Colleen who KNEW, and her colleagues who also blew their whistles)... they DID THEIR JOB... "derided" and "mocked" and sidelined and silenced BUT THEY WERE RIGHT..... "Accountability is a slender thing"... but only for some people (too far up the tree? the 'untouchables' ?)... it's the complexity of the mosiac that allows confusion and escape from consequences... still waiting for RoboDebt architects to get their just 'rewards' but not holding my breath... we count all these costs in deaths - Grenfell, RoboDebt, the debacle that is Aged Care and NDIS... but it's the business models and profits that seem to matter