Lessons from an Architectural Catastrophe: the Grenfell Tower Fire

Architects have long complained of the erosion of their status, seeing their role at the top of the tree relentlessly undermined and usurped by specialist subconsultants […] leaving the architect as an increasingly ineffectual middleman, supposedly presiding over these multiple specialisms while having little technical knowledge of any of them.

The same complaints about erosion of the architectural profession’s status apply in Canada. If architects in Canada are perceived as not meeting the public’s need for their leadership on issues impacting the safety of those that occupy the buildings architects design, is there any reason for our status at the “top of the tree” not to be challenged? Should we be asking ourselves: “As architects, are we engaged enough in meeting the need for leadership?”

The Metropolitan Police said in May 2024 that 180 officers and staff were investigating whether criminal offences had been committed in relation to the Grenfell Tower Fire. They had identified 19 companies or organisations and 58 individuals as suspects.

The police force believed it would take … until at least the end of 2025 … for the investigation team to fully assess the report once it was published … [Early investigative advice files] … examined a full range of offences including corporate manslaughter, gross negligence manslaughter, fraud, and health and safety offences.

Those of us who don’t practise in the UK will recognize that many of the missteps leading to the Grenfell fire shouldn’t happen here—at least not in the same way—where different regulations, different standards, different customs, etc. apply. But we shouldn’t conclude that we are incapable of similar failings. There should be no huge sigh of relief. In each of the problems attributed to firms, agencies and individuals, there exists an unsettling number of parallels to current practices and circumstances here in Ontario.

Beginning with the professional behaviour of the architects themselves—professional negligence, including inexperience, lack of basic knowledge, inadequate fees, lack of preparation, misrepresentation, unawareness of regulations, inadequate standard of care, failure to coordinate, being distracted by other concerns, gullibility, deficient site reviews—all of these show up regularly in professional liability insurance claims against Architects and engineers in Ontario.

Although the TMO [Tenant Management Organization] as the client wanted to reduce the cost by using ACM rainscreen panels, it was the responsibility of Studio E to determine whether the use of such material would enable the building to comply with functional requirement B4(1) of the Building Regulations and advise the TMO accordingly. Its failure to recognize that ACM was dangerous and to warn the TMO against its use represented a failure to act in accordance with the standard of a reasonably competent architect […] Studio E therefore bears a very significant degree of responsibility for the disaster. — 

In claims against Ontario Architects, failure to adequately advise or warn clients about BOTH the benefits and risks associated with its recommendations, including the inadequacies, code compliance, maintenance and other implications of materials proposed for use on a project, show up frequently in claims. I am also aware of legal advice that architects’ errors that result in unsafe buildings and/or do not comply with the OBC could be grounds for professional misconduct.

The lead architect on the refurbishment of Grenfell Tower, which was completed the year before the building caught fire in 2017, has revealed that he was not aware of all the fire safety advice for tall buildings.

Throughout, the report criticizes the architect’s lack of familiarity with and understanding of the significance of building regulations.

Awareness of building regulations, including the applicable provisions in the building and fire codes, is accepted as a given for an architect providing professional services to the public in Ontario. Nevertheless, allegations that an architect has failed to meet the applicable code requirements are common. 

Architects have access to allied professionals who specialize in applying our building codes and applicable standards to any situations that arise where the architect’s knowledge and experience are lacking. But this assistance is only useful if it is sought and used. At Grenfell, failure to utilize the services of an available fire prevention specialist was cited as one of the architect’s failures contributing to the loss of life.

The TMO (Tenant Management Organization) must also take a share of the blame for the disaster. As the [architect’s] client it failed to take sufficient care in its choice of architect.

— Vol.1, Part 6, 2.87

We frequently see similar assertions by Ontario Architects that they are qualified to take on a new type of project (high-rise residential, re-cladding of an existing high-rise apartment building e.g.) based on unrelated experience on other types of projects. Similarly, criticism of clients for putting other considerations—including fees and avoidance of a selection process—ahead of applicable experience are also common.

Many client organizations have protocols for procuring services that they are happy to set aside when convenient—a common rationale for clients asking architects to retain “owner’s specialists.”

But when things go wrong and the circumstances come to light, it tends to become front page news.

Anyone who has been to a degree show or a “crit”, where students present their work to a jury of critics, will know that architectural education is a five-year training in visual representation and rhetorical obfuscation.

As the inquiry panel member Thoria Istephan, an architect and registered health and safety practitioner said as the findings were published: “put simply, if you work in the construction industry and you do not feel the weight of responsibility for keeping people safe, you are in the wrong job.”

There are reports that the RIBA rarely (if ever) sanctions architects for failure to undertake Continuing Professional Development (CPD). By contrast, provincial regulators in Canada, including the OAA, carefully monitor and enforce adherence to required continuing education, and here in Ontario, some courses are mandatory. However, the selection of ConEd courses is made largely by the individual architect rather than in response to identified gaps in the architect’s knowledge—and compliance is mostly based on time spent rather than on knowledge gained.

In risk management discussions, some architects have expressed concern over the limitations inherent in the currently available post-secondary education options and the requirements for admission to the profession, particularly with respect to preparation for managing a practice. There is considerable debate about whether the profession’s standards for entry are appropriate and whether there is enough review regarding the capability currency of knowledge among existing practitioners. 

Happily, to date none of these have been subject to the intense scrutiny that has occurred in the UK in the wake of the Grenfell Tower fire.

The OAA, in partnership with the University of Toronto School of Continuing Studies offers a 12-Module program: Fundamentals of Running an Architectural Practice (FRAP) that assists in filling the gap between qualification for licensure (membership) in the OAA and preparation for practice. Satisfactory completion of the program is confirmed by testing at the conclusion of each module. 

That [the architect] appears to have stamped drawings ‘as approved’ speaks more to their naivety than their negligence.

Rather than mistrusting each other, architects, as professionals, should be distinguished from ordinary members of the public, with the expectation that they will exercise “professional skepticism.” Here, as in the UK, architects deal with manufacturers and distributors’ claims regarding products or assemblies being promoted for use on a project that may not be entirely accurate or complete. Failure to carry out a due diligence review and confirmation of the suitability of the product for the use intended can be considered as an “error, omission or negligence,” and failure to meet the standard of care on the part of the architect.

Quoting Ronald Regan, “Trust…but verify!”

When it did return to carrying out tests on systems incorporating K15, Kingspan did not use the product currently on the market but used modified or trial versions. It dishonestly relied on the results of those tests to support the sale of K15 for use on buildings over 18 metres in height and continued to do so until October 2020.

Perhaps ironically, the Kingspan product and approval cited in the Report was not extensively used on the Grenfell Tower re-cladding. As noted earlier, Celotex RS5000 insulation suddenly replaced it, “without approval by anyone in a position of authority or oversight.”

The Report highlights Kingspan’s role, as an example of a manufacturer/supplier manipulating test results to obtain a fire resistance rating that was not accurate for the product it was selling. This was cited as an example of dishonesty within the testing and approvals procedures in the UK—a deceitful practice that can scarcely be blamed on the UK architect. However, Kingspan is a major supplier of building products in North America. So for us, the obvious conclusion is that, while Inquiry’s mandate did not include testing procedures outside the UK, architects in Ontario and other jurisdictions should take note, and be extra vigilant where product testing is involved. 

Similar concerns about inspection procedures have been expressed regarding the misuse of product evaluations by the Canadian Construction Materials Centre (CCMC) in Canada.

The horrific fire at Grenfell Tower … may emerge as the latest, and most tragic, manifestation of decreasing oversight that architects have been warning about for so long

[…] Design and Build produced a transfer of risk, with the balance of power shifting from the contract administrator (a role most often fulfilled by the architect) to the builder.

Design and build doesn’t just allow a culture of dereliction of responsibility to perpetuate; it positively encourages it.

Ontario architects are familiar with the transfer of authority and diminution of their professional responsibility when they provide services to a builder rather than to the owner of a project under a Design-Build arrangement. For Infrastructure Ontario (IO) AFP (P3) projects, the architect and other design consultants are retained by a contractor in a Design-Build arrangement. Builders or other proponents of this approach have become very adept at transferring their business and other risks down onto the design consultants they retain. Witness the extraordinary efforts of Infrastructure Ontario and its surrogate Project Management Service Providers (PMSPs) to contract out of as much responsibility and liability as possible, coupled with Ontario architects’ and Pro-Demnity’s extensive efforts over the past decade to stay informed about what IO’s approach means for them.

The latest Vendor of Record (VOR) contracts being used by IO’s PMSPs that we have seen are 140 pages long—and essentially incomprehensible to anyone other than the authors themselves, and possibly even to them.

Recent controversy over the continuing inability of Metrolinx—a close cousin of Infrastructure Ontario—to deliver projects “on time and on budget” and the sudden resignation of Metrolinx’s CEO gave rise to an article in the December 4, 2024 Toronto Star written by John Lorinc titled “Infrastructure Ontario must go” that suggests that IO’s procurement policies have one further disadvantage: rather than saving time and expense, they add to the cost of development:

Only when Queen’s Park faces up to this hard truth and jettisons IO’s public-private-partnership approach will we get back to a saner and less expensive way of building infrastructure.

The Architects failed to ensure that [fire safety consultants] completed the fire safety strategy for the refurbished building or advise [the principal contractor– builder] and the TMO [Tenant Management Organization—the architect’s client] that it should be required to do so. 

[The Architect] failed to understand that it was responsible for design work carried out by sub‑contractors and so did not check [the cladding installers’] designs to ensure that on completion the building would comply with the Building Regulations. It did not devise a proper cavity barrier strategy or check [the installers’] designs for the cavity barriers, and it failed to produce detailed drawings of the window reveals or to notice that the materials specified for the window (perimeter) infill panels were unsuitable (combustible).

Architects in Canada have ready access to specialist expertise related to code compliance and fire safety provisions. In fact, Pro-Demnity encourages architects to seek out Building Envelope Specialists (see also our Technical Requirements Schedule). Such expertise can be called upon to assist architects and engineers to confirm compliance with codes and appropriate practice. It can also help to arrive at alternate code compliant performance-based solutions for approval by municipal building officials, as part of the building permit approval process. But such expertise is only helpful if it is used, and the specialist’s advice is followed. 

The Grenfell Tower Inquiry noted that, inexplicably, the fire safety consultant retained for the project had been overlooked and did not have the opportunity to provide its expertise until it was too late—i.e., at the Inquiry hearings. The inquiry concluded that, if consulted, the fire safety specialist would have recognized the unbroken “chimney effect” created by the (150 mm±) width of the air space between the cladding and the existing exterior wall. Furthermore, since the polyethylene core in the ACM insulated panels was highly combustible, as was the insulation applied to the exterior wall of the existing structure, the chimney enclosure itself was extremely flammable.

Poor record-keeping is strongly [criticized], including the failure to ensure that subcontractors’ drawings were complete and accurate, and the endorsement of flawed construction drawings.

Maintenance of complete records related to any professional’s services is an essential professional responsibility and valuable risk management tool. A record of “who said what to whom and when” can make the difference in determining whether an architect—and its subconsultants—have met their duty of care to their client and the public, and adherence to the prevailing standard of care.

The first urges the Architects Registration Board (ARB) and the RIBA to review changes already made to improve the education and training of architects since the tragedy […].

The ARB, meanwhile, has introduced a mandatory scheme for CPD [Continuing Professional Development] applying to all registered architects, and new competency outcomes that all providers of ARB-accredited qualifications must meet.

Evaluation of the currency of qualifications of established practitioners has been a challenge in Canada and Ontario. A Practice Review Program is legislated under Section 52 of Regulation 27 of the Architects Act.

The program, described as “proactive and preventive” is designed to “support the goals of architects to be efficient, effective and competent.” The Guidelines describe the program thusly:

An integral part of the OAA’s mandate to govern the architecture profession in the public interest, the Practice Review Program furthers the goal of quality assurance whenever architectural services are offered to the public.

These reviews are designed to proactively assess the practice management capabilities of a holder of a Certificate of Practice and to identify any deficiencies that, if neglected, could adversely affect quality of architectural services.

Remedial in nature, the Practice Review Program provides personalized guidance aimed at helping members correct deficiencies with their practice management systems in order to avoid serious non-compliance, competence, or misconduct issues. (underling for emphasis)

It is perhaps too early to decide whether the program’s outcomes achieve these objectives. We can hope so.

The Alberta Association of Architects has recently introduced a Compulsory Building Envelope Continuing Education Program. Hopefully, combustibility of materials and control of fire spread will be included in the curriculum.

As noted in Episode 3, the OAA, in partnership with the University of Toronto School of Continuing Studies offers a program: Fundamentals of Running an Architectural Practice (FRAP) that helps fill the gap between qualification for licensure and preparation for practice. 

[T]he TMO [Tenant Management Organization, i.e., the client] must also take a share of the blame for the disaster. As the client, […] paid insufficient attention to matters affecting fire safety, including the work of the fire engineer.

– Vol. 1, Part 6, 2.87

Many residents regarded [the TMO] as an “uncaring and bullying overlord that belittled and marginalized them, regarded them as a nuisance, or worse, and failed to take their concerns seriously,” the report said.

Ontario architects will recognize similar complaints reported in the media involving difficult tenant–landlord relationships inherent in municipality-owned publicly assisted housing in major Ontario cities. Architects may be retained to assist in upgrading these projects; however, meaningful involvement of the tenants in the project definition and planning is not assured. Hopefully matters impacting the tenants’ quality of life and life safety identified by the tenants themselves are given more attention than was evident at Grenfell Tower. 

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.

— Vol. 1, Part 3, 2.19

Celotex (one of two companies that made the re-cladding insulation] embarked on a dishonest scheme to mislead its customers and the wider market.

— Vol. 1, Part 3, 2.28

The dishonest strategies of Arconic [supplier of the polyethylene core ACM panels through a French subsidiary]and Kingspan succeeded in a large measure due to the incompetence of the BBA [British Board of Agrément—construction certifiers], its failure to adhere robustly to the system of checks it had put in place, and an ingrained willingness to accommodate customers instead of insisting on high standards and adherence to a contract that was intended to maintain them.

— Vol. 1, Part 3, 2.42

It is expected that suppliers of building products and systems will want to focus owners’, architects’ and specifiers’ attention on the more positive attributes of the products they manufacture and sell. If an architect is interested in appearance or availability of colours or finishes, those aspects will be the focus of the discussion. Few suppliers’ representatives will go out of their way to advise an owner or architect that the product is unsuitable for the intended use, although we are aware of exceptions, including instances where an owner has rejected the supplier’s and architect’s advice about unsuitability in favour of lower cost or immediate availability.

In these circumstances, architects can be whipsawed between the interests of their client (who pays their fees) and the Public Interest that they are expected to protect—a very difficult situation to navigate but one which, especially in cases pertaining to life safety, must be resolved in favour of the Public, as part of an architect’s professional duty. An architect may compromise on some aspects of a design that are unsuitable but preferable to the client (e.g., ease of maintenance, durability, aesthetics), as long as their advice to the contrary is documented. However, they cannot compromise on significant life safety matters and may even need to resign from a project if their client doesn’t listen.

As noted earlier, architects are expected to exercise “professional skepticism” with respect to any product supplier’s claims recognizing that the supplier’s objectives may not be aligned with the architect’s duty of care and obligation to protect the Public Interest. Exercising one’s professional skepticism is an important risk management tool for architects and their subconsultants.

A Principal Research Officer at the Canadian National Research Council reviewing the Grenville Tower Inquiry Phase 2 Report noted how important it was that entities responsible for testing products and assemblies for compliance with required safety standards act “independently”—i.e., “stick to the rules” inherent in the test requirements.

The Lakanal House fire in July 2009 should have alerted the LFB to the shortcomings in its ability to fight fires in high-rise buildings that revealed themselves once more at Grenfell Tower on the night of June 14, 2017 […]. Importantly, it failed to ensure that in the years immediately preceding the Grenfell Tower fire regular training of a suitable kind was provided to its control room operators on handling many fire survival guidance calls concurrently and on their duties more generally.

— Vol. 1, Part 1, 2.90

Firefighters were not given proper training or guidance on how to carry out inspections of complex buildings and there were no effective arrangements for sharing information about risks posed by particular buildings.

— Vol. 1, Part 1, 2.94

In Ontario, architects need to recognize and satisfy the requirements of BOTH the Ontario Building Code and the Ontario Fire Code. The latter establishes minimum requirements for fire safety within and around existing buildings and facilities, including requirements for safe evacuations through the use of fire alarms, fire extinguishers and fire escape routes. 

The OFC contains requirements for the construction of buildings with fire-resistant materials (as per code standards) to help lessen fire damage. Of special importance in this context is the requirement for Fire Escape Plans accessible to all occupants of a residential building.

Although the Municipality’s Chief Building Official has the authority to determine which provisions apply where there is a conflict between the requirements of the OBC and OFC, most building Officials defer to the Fire Department, recognizing that in the event of a fire, it is the fire service that has the front-line duty to save lives with the equipment and resources available. Architects (and owners) can find this frustrating, particularly when the Fire Department’s enforcement officer demands changes to already constructed facilities at the last minute, in order to secure an occupancy permit. Pro-Demnity regularly sees claims for delay caused by the architect who had not anticipated the Fire Department’s position. Such claims can and should be avoided, but we would prefer to see those claims than an Ontario version of Grenfell Tower.

The [UK] government’s deregulatory agenda, enthusiastically supported by some junior ministers and the secretary of state, dominated the department’s thinking to such an extent that even matters affecting the safety of life were ignored, delayed or disregarded.

From the earliest days of the Inquiry there have been those who have asserted that discrimination on the grounds of race or social background played a significant part in the tragedy that befell Grenfell Tower on 14 June 2017. […] Those calls reflected a widely held belief that people of minority ethnic and socially disadvantaged backgrounds were routinely the subject of active discrimination that took the form of making available to them low quality or unsafe housing.

Any examination of social housing policy more widely would have extended that task enormously. As a result, the Prime Minister decided not to include those matters in the Inquiry’s Terms of Reference

We […] have seen some evidence of racial discrimination in the way in which some of those who survived the fire were treated in the days immediately following it at a time when they were at their most vulnerable […]. We have also seen evidence that the TMO failed over the course of years to treat residents of the tower and the Lancaster West Estate, more generally, with the courtesy and respect due to them.

Canadians in 2025 are considerably more aware of Diversity, Equity, Accessibility and Inclusion than a decade ago, and of the need to reflect those same values in the built environment. A good example of how our thinking and practices have changed is the new and still emerging replanning and rebuilding of the new and diverse neighborhoods located on the site of the former post-war Regent Park, in Toronto—Canada’s first social housing complex.

A December 2016 article in The Guardian, “Inside Regent Park: Toronto’s test case for public-private gentrification,” published a mere six months prior to the Grenfell Tower fire, provides an interim report on progress of the transformation, as an apparent reversal of an otherwise universal trend to “buy the public housing sites, evict low-income tenants, blow up the old buildings and build mostly new luxury apartments that the original tenants can’t possibly afford.” By contrast, Regent Park 

attempts to shrug off its violent reputation by integrating upmarket living with public housing, it has attracted global attention as a kind of socio-economic experiment in public-private gentrification. For better or worse, this one-time crime haven in Toronto has become a test: can you regenerate social housing without resorting to social cleansing?

Unlike the circumstances at Grenfell Tower and earlier Canadian examples, planning policies and building codes in Canada are now beginning to consider “places of refuge” for tenants/occupants with disabilities to shelter outside their units on each floor until they can be safely evacuated by the fire service in the event of a fire, as noted in the government of Canada document “Planning for Safety,” Section 3, Areas of refuge/rescue assistance

Areas of refuge/rescue assistance are required under the Canadian Standards Association’s Accessible Design for the Built Environment standard (CAN/CSA B651-04) and these requirements are beginning to appear in building codes. Areas of refuge have successfully been in use in British Columbia for decades.

The failure of RBKC [Royal Borough of Kensington and Chelsea] to meet the basic needs of those displaced in the days immediately following the fire demonstrated the need for local authorities to have effective plans in place for providing humanitarian assistance.

— Part 13,113.72

Most importantly, there was a failure to create a climate in which concerns reaching the department about matters affecting safety could be raised with senior officials and frank advice given.

Does anyone imagine that the current situation in Canada and Ontario is significantly better? Consider that:

• The provincial and federal governments are currently engaged in the worthy endeavour of “encouraging” the construction of more housing, more quickly, with the inevitable result that some regulations and procedures may need to be sidestepped—with too little concern for the consequences.
• Nowhere is the objective of “better” housing specifically mentioned.
• In 2022, the Ontario government identified an intention to amend the Building Code to allow for a single means of exit in four-to-six storey residential buildings as part of its Housing Supply Action Plan. In Toronto, councillors have considered a feasibility report that could make it easier to construct buildings of up to four storeys using only one exit stair, as opposed to the current requirement of two staircases prescribed in the Ontario Building Code. At least most (but not all) fire services in Ontario have a reasonable chance of extinguishing a fire in a four- to six-storey wood frame building. Whether the occupants and the firefighters will both be able to survive sharing a single stair access/egress route is another question. 
• We anticipate that there may be advocates for further changes to the codes to reduce the current requirement for two means of egress in high-rise buildings to one. If this proves correct, we might conclude that the consequences of a single means of egress (and access for fire fighters) that contributed to the loss of 72 lives at Grenfell Tower, had little impact on those advocating for such a change

Demands for funding support required to help our municipalities meet the demands for necessary infrastructure—water service with adequate flows and pressure—as well as necessary equipment and trained fire fighting personnel to support the political “more housing faster” objectives are always uncertain, competing with every other good idea for the expenditure of public funds, and a political culture of “spend less.”

Hassan Ibrahim, who lived in an apartment on the 23rd floor of Grenfell Tower, was traveling outside England the day of the fire. His wife, Rania, and their two small children were not so lucky. As the smoke and flames drifted upward, Ms. Ibrahim debated with a neighbor whether to risk opening her door.

We are on the last floor. The last floor is the one that has not caught fire yet … It’s over. It is here … Pray for us.

What can we—architects, and a professional liability insurance company protecting and defending architects—do to help ensure that the circumstances that caused and contributed to the Grenfell Tower catastrophe are not repeated here? 

That is a very challenging question without easy, one-size-fits-all answers. But one thing is certain: First, we all need to care about those who rely upon us to do our jobs thoroughly and well. 

Perhaps Dr. Seuss was speaking to us at the conclusion of his much-loved 1971 children’s story The Lorax:

“Unless someone like you cares a whole awful lot, Nothing is going to get better: It’s not.”