On 4 September 2024 the public inquiry into the Grenfell Tower fire in London published its final report. The fire on 14 June 2017 began in the kitchen of a flat at 00.54 and then spread rapidly through the combustible facade system (McKenna et al., 2019). The report asks how a reinforced concrete building, itself structurally impervious to fire, could be turned into a death trap within a few hours (Grenfell Tower Inquiry, 2024). In Parliament the same day, the UK Prime Minister quoted the chairman's conclusion that the deaths were all avoidable, apologised, and spoke of the 72 people who died (Prime Minister's Office, 2024).
This case study rests on the executive summary of that official report. We do not name the victims or the companies, because the focus is the system rather than individuals.
Summary of Findings
The report concludes that the fire was the culmination of decades of failure by central government and other bodies in the construction industry to look carefully into the danger of combustible materials in the external walls of high-rise residential buildings and to act on what they knew. One very significant reason the tower was clad in combustible materials was systematic dishonesty by the makers of the rainscreen panels and insulation products, who deliberately manipulated testing, misrepresented test data and misled the market. Those strategies succeeded partly because product certification bodies failed to ensure that the statements in their certificates were accurate and based on test evidence (Grenfell Tower Inquiry, 2024).
On the refurbishment project, the building manager's emphasis shifted to saving cost around May 2013. The architect had wanted zinc panels, but aluminium composite material (ACM) with a polyethylene core was eventually chosen, largely on grounds of cost. Everyone involved in choosing the external wall materials thought responsibility for their suitability and safety lay with someone else. The report also records a deteriorating relationship between the manager and residents, residents' concerns that were not taken seriously, a single fire risk assessor for the whole estate, and a backlog of remedial work from fire risk assessments that was never cleared (Grenfell Tower Inquiry, 2024).
Technical Factors
Laboratory research explains why that choice of materials proved fatal. Compared with the least flammable panels, polyethylene-aluminium composites showed 55 times greater peak heat release rate and 70 times greater total heat release. Polyisocyanurate foam insulation showed 16 times greater peak heat release rate than the least combustible insulation, a few burning drips of polyethylene were enough to ignite it, and its smoke was 15 times more toxic than smoke from mineral wool (McKenna et al., 2019).
The risk is also relevant in Indonesia. Research by the building science centre of the Ministry of Public Works and Housing notes that ACP is commonly used as a building envelope cladding, while ACP on the market has generally not been tested against fire resistance standards. An intermediate-scale test of non-fire-rated ACP with a polyethylene core showed flame travelling quickly from bottom to top through the gap between panel and wall, which behaved like a chimney (Hariono et al., 2023).
Governance Analysis
We read these findings through Reason's (1997) model of organisational accidents, which separates active failures at the front line from latent conditions built into organisational decisions long before an event. Almost every major factor at Grenfell was a latent condition: unclear regulatory guidance, manipulated test data, unchecked certificates, cost-driven procurement decisions and a complaints channel that did not work. These conditions took shape years before the night of the fire.
From an ESG standpoint we see three lessons. First, supply chain governance: supplier certificates and data sheets cannot simply be accepted, because the report shows they can be inaccurate. Second, blurred accountability: when every party assumes another is checking safety, important technical decisions have no owner. Third, stakeholder voice: residents' complaints are risk data, and the report judged that the building manager failed to treat them that way. The business consequences are real too, as the UK government said it would write to all companies found by the inquiry to have been part of the failings as a first step to stopping them being awarded government contracts (Prime Minister's Office, 2024).
The limits of this analysis should be stated. We draw only on the executive summary of a seven-volume report, and the UK building regulatory system differs from Indonesia's, so findings about particular institutions cannot be transferred directly.
Lessons for Building Owners
- Inventory building envelope materials, especially ACP and insulation, together with fire test evidence rather than catalogue claims.
- Decide who may approve material changes when a project is cut back on cost, and require a fire safety review for every substitution.
- Verify supplier documents independently for materials that are critical to safety.
- Close out fire risk assessment findings and report outstanding items to the board.
- Treat residents' or workers' safety complaints as risk input that is logged and answered.
How Nusa Safety Helps
Nusa Safety helps building owners and managers assess the safety condition of their buildings, including envelopes and compartments, through a Building and Facility Safety Assessment, and tests the readiness of fire protection and emergency response through a Fire and Emergency Safety Audit (FESA). For control of contractors and suppliers, the Nusa Safety team offers an HSE and CSMS Audit.
This article is general information and not legal or professional advice for any specific case.
References
- Grenfell Tower Inquiry. (2024). Grenfell Tower Inquiry: Phase 2 report, Volume 1 (HC 19-I). His Majesty's Stationery Office. https://assets.publishing.service.gov.uk/media/66d817aa701781e1b341dbd3/CCS0923434692-004_GTI_Phase_2_Volume_1_BOOKMARKED.pdf
- Hariono, A., Laksono, A. P., Prasetia, R., & Agustio, M. F. (2023). Performansi keselamatan kebakaran penggunaan aluminum composite panel (ACP) pada bangunan gedung [Fire safety performance of the use of aluminium composite panels in buildings]. Jurnal Permukiman, 18(2), 92-102. https://doi.org/10.31815/jp.2023.18.92-102
- McKenna, S. T., Jones, N., Peck, G., Dickens, K., Pawelec, W., Oradei, S., Harris, S., Stec, A. A., & Hull, T. R. (2019). Fire behaviour of modern façade materials: Understanding the Grenfell Tower fire. Journal of Hazardous Materials, 368, 115-123. https://doi.org/10.1016/j.jhazmat.2018.12.077
- Prime Minister's Office. (2024, September 4). Prime Minister's statement on Grenfell Tower Inquiry final report: 4 September 2024. GOV.UK. https://www.gov.uk/government/speeches/prime-ministers-statement-on-grenfell-tower-inquiry-final-report-4-september-2024
- Reason, J. (1997). Managing the risks of organizational accidents. Ashgate.
