2009年，伦敦南部14层的Lakanal House发生了一场小火灾。火焰蔓延到住宅区的可燃覆板，然后以惊人的速度和凶猛的速度点燃，让消防队员感到困惑。大火导致6人死亡，其中包括3名儿童。当时，这是英国最严重的高层建筑火灾。

Nearly eight years later, this disaster was dwarfed by the fire at Grenfell Tower in June 2017. Just as at Lakanal House, a small internal fire catastrophically escalated when it spread to the building’s combustible cladding – except at Grenfell it engulfed almost the entire 24-storey building and killed 72 people.

2014年，在Lakanal之后五年多的时间里，建筑专业人员指定了格伦费尔使用的覆板，用于该街区的翻新。尽管针对后者开展了建筑法规审查，但在格伦费尔火灾发生时，这些法规并没有改变。与此同时，英国各地数以百计的高层住宅楼安装了可燃材料，造成了一场安全危机，需要花费数十亿英镑来解决。

Over the past month, the Grenfell Inquiry has seen a roll-call of senior government figures asked to explain how this had happened. Key figures who have provided evidence included Eric Pickles, housing secretary between 2010 and 2015, and former ministersBrandon Lewis,Gavin BarwellandStephen Williams. Other significant witnesses have includedBrian Martin, the civil servant in charge of building regulations for nearly 18 years before the Grenfell fire, and his colleaguesBob LedsomeandMelanie Dawes. It has been the culmination of the phase of the inquiry looking into the causes of the fire, with hearings now set to move on to what happened in the aftermath.

Change that never happened

A key focus has been the government’s handling of the review of building regulations in the years leading up to the Grenfell fire. In 2013, the findings of an inquest into the Lakanal House fire included recommendations that the government should amend a small section to clarify the risk of external fire spread. But almost no progress had been made by the time of the Grenfell fire aside from some preparatory research, and the building regulations were not updated to explicitly ban combustible cladding panels until December 2018.

道斯是当时的社区和地方政府部门(DCLG)的前常任秘书，他说这些建议并没有被认为“对公共安全特别重要”。她说，这是因为负责监管的官员认为验尸官弗朗西丝·柯卡姆(Frances Kirkham)的建议“写得不是特别好”，“可能对这些建议有点不屑一顾”。

It was said that I shouldn’t worry, there wasn’t any real issue in terms of safety, people know these kinds of thing

Eric Pickles, housing secretary between 2010 and 2015

马丁对这些规则非常熟悉，他把它们比作自己的“第三个孩子”。他还表示，建议柯卡姆的专家证人“感到困惑和矛盾”，所以验尸官要求澄清这些规则“并不奇怪”。皮克尔斯说，这“肯定影响了”他对遵守这些建议重要性的判断。

“It was said that I shouldn’t worry, there wasn’t any real issue in terms of safety, people know these kinds of things,” the former secretary of state added. Nevertheless, the government had agreed to implement the review.

但它很快就遇到了问题，部分原因是戴维•卡梅伦(David Cameron)领导的联合政府推动放松管制。2011年，日本内阁府(Cabinet Office)引入了“繁文缛节挑战”(red tape challenge)，限制各部门在取消现有规定的情况下，只能增加新的规定。金融危机爆发后，为了刺激经济而实施的“一进一出”政策，在2013年和2016年分别加强为“一进二出”和“一进三出”。这意味着修改法规的工作变得极其复杂，因为官员们需要通过选择哪些规则必须被删减来平衡任何增加的规则。

Partly because of this, the amendment of a small section of official guidance recommended by Kirkham was expanded to include a review of the entire 300-page Approved Document B, the part of building regulations that deals with fire safety. It was then expanded further to encompass a wider review of building regulations, a process which would take years.

Barwell, the housing minister between 2016 and 2017, told the inquiry that there had been a “clear presumption” that the review into building regulations was not “life safety critical” because it had been wrapped into a much longer-term piece of work. He also said he had been “comforted” by figures shown to him by officials which showed that the number of fatalities from fires had been steadily falling for 30 years.

In this environment, evidence suggests that the urgency of Kirkham’s recommendations had been lost. A set of research documents underpinning changes to the regulations which had been delivered to the department in March 2015 was not published until February 2019, a delay which Barwell admitted was “absurd”.

Martin said that his team had “really struggled to get anything done” within the department because regulation was seen as a “dirty word”. He suggested that political disruption following the 2016 Brexit vote had made it even harder to get “any kind of traction” with proposals for regulatory changes.

Drive for deregulation

那么，考虑到消防法规关系到生命安全，官员们为什么不要求将其排除在放松管制的努力之外呢?建筑法规的前副主任莱德索姆说，他和他的任何同事都没有这么做，因为他认为这是一场“值得的战斗”。

Pickles said his reaction was “intense impatience” when shown this evidence. He told the inqury this month: “I’m not saying I would have agreed with Mr Ledsome. But I think I’m entitled to have had a chance to do the right thing or do the stupid thing.”

Ledsome had said he would have had to persuade Pickles to make the case to then-business secretary Vince Cable, who was responsible for decisions on regulating industry. There would have been an “enormous amount of horse-trading”, Pickles admitted, but he added: “You don’t help the politician to take a decision unless you confront them with the reality.”

But the former minister admitted that he himself was in favour of deregulation at the time. “Of course I wanted to deregulate,” he said. Asked if he was aware that officials felt they were working in a policy environment where regulatory intervention was seen as a last resort, he said: “Well, that isn’t a bad thing, is it? To have a system where… we’re not going to jump straight into regulation, that strikes me as being a good thing.”

He also said thatclaims that deregulation had restricted efforts to toughen up fire safety guidance were “ludicrous”, as he had believed they were, in fact, exempt. Asked if he could explain how his officials seemed to have been “labouring under a misapprehension”, Pickles said they had been “making assumptions”.

调查顾问理查德·米莱特QC提供了另一种解释——皮克尔斯与他自己的部门“极度脱节”，现在正试图“重编故事，淡化你们政府对放松管制议程的热情，这实际上导致了生命安全方面完全缺乏适当的制衡。”

Pickles said this was “unkind”, adding: “Without getting terribly emotional, I swore on the bloody Bible. I’m a Christian. I wouldn’t come here to… try and just remove responsibility. These things are important to me.”

Warning signs ignored

在此期间，有关消防安全的多党议会小组(APPG)多次警告该部门，称建筑法规存在缺陷，需要“立即关注”。在过去的几年里，APPG已经向住房部长们发送了一系列冗长的信件，要求制定更严格的消防安全指南，但由于该部门缺乏行动，他们越来越感到沮丧。

Barwell had declined a meeting with the APPG in October 2016, something he said he now “deeply regrets”. He later agreed to a meeting in March 2017, against the advice of his officials, but this never happened because of that year’s snap general election, at which he lost his seat.

Officials had been aware of concerns about the regulations among industry professionals for several years. In July 2014, Martin had attended a meeting of cladding experts called by the Centre for Windows and Cladding Technology (CWCT), an industry body, to discuss concerns over an ambiguous passage in the official fire safety guidance. The passage appeared to imply that the requirement for the tough fire standard of “limited combustibility” in cladding systems only applied to “filler” materials.

The inquiry heard that this term, which had been inserted by Martin and his colleagues in 2006, was a last-minute addition and had not been consulted on with the construction industry. It was also contained under the heading “Insulation Materials/Products”, leading many professionals to conclude that it only referred to insulation products and not cladding panels. It meant that ACM panels, which contain a highly combustible plastic core and were the type used for the refurbishment of Grenfell Tower, were seen by some as permitted by the guidance.

It was a problem which was really peculiar to ACM, and I just didn’t think it was that significant an issue at the time

Brian Martin, civil servant in charge of building regulations in the years prior to the Grenfell fire

米莱特表示，由于法规中“起草不当”的条款，这导致了“英国建筑业10年来的误解”。马丁，尽管会议纪要显示，他同意措辞是“不清楚的”，坚持在听证会上，该术语也指的是核心的覆板，如ACM。

The government also stuck to this line when details about the passage first emerged in the press in the days after the Grenfell fire, with the inquiry hearing that Martin had emailed product testing body the Building Research Establishment (BRE) with a “pre-prepared script” to use for a defence of the regulations.

After the CWCT meeting, it was agreed that Martin and the BRE would draft a clarification of the word “filler” to be published on the government’s website in the form of a “frequently asked question” (FAQ). But the clarification was never published, and the passage in the guidance was unchanged until 2018. The timing of the meeting was significant, as it came months before the project team working on the refurbishment of Grenfell Tower decided to use ACM panels in the cladding system.

Martin, who the inquiry heard was the person to whom “everyone would turn” at the housing department for advice on fire safety issues, said he had decided to wait for the experts who attended the meeting to contact him with proposals. This does not appear to have happened, andMartin said he then “probably forgot about it”as it had been a “busy time”.

His colleagues, Anthony Burd, Ledsome and Richard Harral, have all told the inquiry that issuing the FAQ was not a difficult piece of work and could easily have been done by the fire safety team in the department. Martin also accepted that there was nothing “unreasonable or inappropriate or disproportionately difficult” in publishing the FAQ.

Growing concerns over ACM panels

Asked if the reason he had done nothing to clarify the passage was because he did not consider there was any risk of a major fire in England and Wales due to the use of ACM panels, Martin admitted that he “completely underestimated the hazard” and would have put more time into the issue if he had “fully understood it”. He also said he had not raised the lack of clarity in the guidance on ACM with any other senior official at the time, admitting: “I don’t think I recognised how serious it was. It was a problem which was really peculiar to ACM, and I just didn’t think it was that significant an issue at the time.”

Two years later, Martin was warned again about what was unfolding in the construction industry. In 2016, he was sent an email from cladding professional Nick Jenkins which warned of “grave concern” that the number of tall buildings in the UK fitted with ACM cladding was “many and growing”. Martin responded by saying that fire caused by ACM “shouldn’t be a problem in the UK” because the building regulations were “designed to prevent this”.

The department continued to receive warnings about ACM right up until the Grenfell fire. In April 2017, two months before the fire, the London Fire Brigade (LFB) sent a letter saying that it was “deeply concerned” about blocks of flats and other buildings including schools. Commissioner Dany Cotton said the LFB had discovered at least one property each month since the beginning of the year with “significant” fire safety issues, and that it was “safe to assume that there are many other cases that do not come to our attention, yet are placing the residents of those properties in significant risk”.

[There was] progressive decay in the construction industry, the progressive decay that went alongside it in the building control world, the impact of government policy on regulation

Brian Martin

Cotton also said that the LFB was “concerned about contractor competency” and asked to discuss wider issues in relation to the quality of housing. Barwell said he found the letter to be “the most disturbing” of all the evidence shown to him at the inquiry. But he did not receive it at the time because he had been campaigning for the election. The Grenfell Tower fire occurred on 14 June, just six days after the election concluded.

Evidence provided over the past month would suggest that a combination of deregulatory policies designed to jump-start the sluggish post-recession economy and a complacency about fire safety because of the falling numbers of fire deaths played a role in allowing the Grenfell fire to happen. Austerity-era cuts were also a factor, with Martin saying he had been left as a “single point of failure” in an under-resourced department. But this phase of the inquiry has shed light on many things happening at the same time in the years leading up to the fire.

Asked why it took the Grenfell Tower disaster for the dangers of ACM cladding to be fully appreciated, Martin said that it was the “progressive decay in the construction industry, the progressive decay that went alongside it in the building control world, the impact of government policy on regulation and the resources available to try and address these risks”.

All of this has played out against the backdrop of housing secretary Michael Gove’s campaign to get developers and product manufacturers to pay into a £4bn fund for cladding remediation costs for which, he says, the industry shares responsibility. But, with five modules of the inquiry still to go, as well as a police investigation, it is far too early to draw conclusions about where exactly that responsibility rests.

What is safe to assume is that the evidence heard in recent weeks is adding to the argument that firms had been operating within the regulatory environment set by ministers. The timing of Gove’s threats to hold housebuilders and manufacturers to account through the Building Safety Bill could be seen by some as rather convenient for the government.