Grenfell need not have happened. So why did it?

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Hindsight is 20/20 vision, the saying goes – but perhaps the most shocking aspect of the Grenfell inquiry as it unfurls, day after grim day, is just how blind contractors and overseers seemingly were to the risks they were seeding in a tower full of people, full of life. As one safety precaution after another was overlooked or discarded, the 2016 refurbishment of the tower had – as Sam Stein QC put it – turned Grenfell “from a basically safe vertical village to a combustible death trap”.

The word “failed” recurs throughout the inquiry like a tolling bell. The fire safety breaches included more than 100 fire doors that failed to meet building regulations. A smoke extraction system for lobby areas failed. Risers meant to channel water to the top floors of the building failed. The lift intended for fire-fighting equipment failed. An expert fire engineer, Colin Todd, said that it appeared that the aluminium composite cladding used on Grenfell – and more than 300 other English residential tower blocks – had, unbelievably, never been subjected to a full English Standard fire test.

As we know, this cladding was fully tested on the night of Wednesday June 14 2017, killing 72 people in an inferno that engulfed the entire building with what – even to veteran fire-fighters – seemed like astonishing rapidity.

If this part of the inquiry is devoted to establishing how the disaster happened, the following question is: “Why?”

Why were residents’ urgently expressed concerns about fire safety overlooked? Why did a culture of such rotten complacency establish itself so thoroughly? Our public often likes to joke about Britain as a country that does things by the book, that is dominated by myriad inspectors with a box-ticking culture of “health and safety”. The detail of the Grenfell fire has shown that assumption to be frighteningly outdated. The inquiry has already exposed a well of utter corporate recklessness in the heart of London.

Grenfell happened, in part, because it hadn’t happened in exactly the same way before. A modern tower block had not previously turned, in its entirety, into a blazing conflagration with mass loss of life. Professional contractors did not viscerally believe that it could happen on this scale – even though they should have been rationally aware that it could, particularly as every practical safeguard to prevent such a tragedy was steadily being relaxed or removed.

Central to many disasters in which human oversight has played a crucial role is a fundamental belief that the worst cannot happen. The Titanic carried a total of 20 lifeboats – enough to save only one third of her total capacity – when she could have carried up to 64. The crew had never been trained in carrying out an evacuation.

Warnings about ice were not prioritised. Everybody believed that the ship was unsinkable, and so these other considerations were deemed irrelevant. Although smaller ships had previously been lost to the ice, the Titanic’s captain had said in 1907 that he “could not imagine any condition which would cause a ship to founder. Modern shipbuilding has gone beyond that.” By believing disaster to be impossible, those in authority shaped the very conditions by which it occurred.

Many of these failures of human imagination also apply to Grenfell, yet it differs in this regard. In the case of Grenfell, there was indeed one acutely relevant warning from recent history, for anyone who cared to take note. It was the Lakanal House tower block fire in Camberwell, south London, in 2009, in which six people died: three adults and three children.

The inquest report on Lakanal makes deeply chilling reading today: so many details of the Grenfell disaster were foretold. It found that Southwark Council had neglected to perform necessary fire inspections that would have discovered that refurbishment in the 1980s had rendered the block unsafe. The fire, in a ninth-floor flat, spread upwards and downwards with surprising speed. Those who died could have saved themselves and their children, but were wrongly told to remain inside by emergency operators, in the false belief that “compartmentation” in tower blocks would contain the blaze in one flat.

Harriet Harman, the local MP, summed it up thus: “A perfectly safe building became unsafe because of the way that they did the refurbishments.”

It has been alleged in the Grenfell inquiry that the “stay-put” advice from fire-fighters – which officially remained in place until 2.47am – contributed to the high death toll and should have been abandoned much earlier.

That may well be true, and it will no doubt agonise the fire-fighters involved – many of whom behaved with exceptional personal courage – even to consider that a different policy might have saved more lives. Compartmentation, after all, had already failed at Lakanal.

Yet we should also remember that they were in the thick of a very fast-moving conflagration, in a building with a single evacuation staircase that was originally built in 1974 to contain fires within a single flat.

In times of disaster, the emergency services tend to fall back on the template they are most familiar with: the challenge for any commander is to adjust it swiftly in circumstances of extreme panic and unknowable factors and outcomes. Ordinary people, too, behave in unpredictable ways, some running, some clinging desperately to what is familiar.

Lakanal House should have rewritten the fire safety protocol for London tower blocks. Shamefully, it didn’t. After that, Grenfell was very far from unimaginable, yet too many people still acted as if it was.

We should, however, be able to forgive some of the wrong decisions made in the raw heat and panic of that gruelling night, and learn from them. What we should not forgive are the ones taken well in advance, in the cold, clear light of day.