格倫菲爾報告：調查的主要發現

The final report of the Grenfell Inquiry has been published, revealing a series of failures by both the government and private companies that contributed to the tragic fire at Grenfell Tower in 2017, which resulted in the loss of 72 lives. The report, which spans 1,700 pages, outlines how the building's cladding was the primary factor in the rapid spread of the fire. The inquiry took six years to complete, and it highlights several critical findings. One of the most alarming points made in the report is that warnings about the dangers of cladding fires were issued as far back as 1992. After a fire at Knowsley Heights, an 11-story building in Huyton, Merseyside, experts raised concerns about the safety of cladding materials. In 1999, another fire occurred at Garnock Court in Irvine, North Ayrshire, prompting a committee of MPs to reiterate these concerns. Despite these warnings, the government did not take action to ban the flammable cladding, as it was deemed to meet British safety standards. The inquiry also revealed that safety tests conducted in 2001 showed that the type of cladding used on Grenfell burned violently. However, the results of these tests were kept confidential, and the government failed to implement stricter regulations. The inquiry panel expressed confusion over the lack of action regarding such a critical issue. In 2009, a fire at Lakanal House in South London claimed six lives, and the coroner requested a review of building regulations. Unfortunately, the inquiry found that this request was not treated with the urgency it deserved. The report also criticized the coalition government, led by David Cameron, for its focus on reducing regulations, which they referred to as 'red tape. ' This approach led to safety concerns being ignored or delayed, with the inquiry noting that the housing department was poorly managed and fire safety was left to a relatively junior official. The Building Research Establishment (BRE), a key organization responsible for setting safety standards in the UK, was privatized in 1997. The inquiry stated that this privatization exposed the BRE to unscrupulous product manufacturers, further complicating safety issues. The report found that there was systematic dishonesty from companies involved in the production and sale of the cladding. Arconic, a manufacturer, was found to have deliberately concealed the true dangers of the cladding used on Grenfell Tower. Fire tests commissioned by Arconic showed that the cladding performed poorly, but this information was not shared with the British Board of Agrément (BBA), which is responsible for keeping the construction industry informed about safety standards. This lack of transparency led the BBA to make statements that were false and misleading. The inquiry also examined the roles of two companies, Celotex and Kingspan, which produced the insulation used in the cladding panels. Celotex was found to have made false claims about the suitability of its product for Grenfell, while Kingspan misled the market by not disclosing the limitations of its product. The inquiry criticized the management of Grenfell's refurbishment, stating that the contractors and the Tenant Management Organisation (TMO) showed indifference to fire safety and the needs of vulnerable residents. The TMO failed to order the correct specifications for self-closing fire doors, which are crucial for preventing the spread of smoke and flames. The inquiry described a 'merry-go-round of buck-passing' during the building's refurbishment, where no one took responsibility for safety standards. The architect, Studio E, the main contractor, Rydon, and the cladding subcontractor, Harley Facades, all failed to understand their obligations. The inquiry stated that Studio E bore a significant degree of responsibility for the disaster, as they did not recognize that the cladding was combustible. Harley Facades also bore significant responsibility for not considering fire safety at any stage. Rydon failed to clarify which contractor was responsible for what, and they did not take an active interest in fire safety. The London Fire Brigade (LFB) had been aware since the 2009 Lakanal fire that they faced challenges in fighting fires in high-rise buildings. However, the firefighters who responded to the Grenfell fire were not adequately prepared for the situation they encountered. The inquiry found that senior officers were complacent and lacked the skills to address the problems. There was a failure to share knowledge about cladding fires, and the LFB did not plan for a large number of emergency calls or train staff on how to assist trapped residents. Ultimately, the inquiry concluded that the Grenfell disaster was the result of decades of failures in building safety management in England and Wales. It recommended the establishment of a single regulator, accountable to a government minister, to ensure that officials and the industry are held responsible for their actions.