This is part Three of the case study. For Part one (Titanic) click here. For Part two (Costa Concordia) click here.



I play football every Sunday at Westway Sports Centre, London, right in front of the Grenfell Tower in North Kensington. The day after the fire, and for several weeks, the entire area was covered in ash and burned debris. It was an apocalyptic sight. The sports centre was shut down for months as it became an emergency refuge for residents. The area was declared a ‘crime scene’ and it also became a place to grieve for families, residents and the many visitors like me, from UK and the world, who had been deeply touched by the disaster. I often visit there, the shrines and walls of tributes to the fire victims, the pictures of lost ones, entire families, all gone.

I now see the burned dark tower of Grenfell every time I play football. Playing there for me now has a totally different meaning, it makes me sad and mad at the same time. I am Italian. People of many nationalities died there. Some of my fellow citizens (young couple Marco Gottardi and Gloria Trevisan) perished at the Grenfell Tower Fire of 14th of June 2017. I can only imagine what they were feeling in their last moments. Unlike the Titanic and Costa Concordia case studies, Grenfell for me became personal. I was compelled to include and analyse Grenfell Fire as part of 3 case studies on improving governance and organisational culture. It has been emotionally draining to write.

I met Marco’s parents, Giannino Gottardi and Daniela Burigotto during the presentation of their book about Marco & Gloria titled ‘The Knight and the Princess’ at the Italian Cultural Institute in London. The book is a fairy tale written by Marco’s mom Daniela about her son Marco, a courageous knight, that saves Gloria from an evil dragon. Unlike the Grenfell story, this book has a happy ending. During my few minutes with Marco’s father, Giannino, I managed to discuss some of the issues relating to the Grenfell tragedy including the corporate and public failures leading to the tragedy. Grenfell is now the deadliest fire in mainland Britain since they started keeping close records at the start of the 20th century. 72 lives were lost. This case study will show the crucial corporate and public governance failures that led to the event so that crucial lessons can be learned and avoided in the future.

London’s firefighters went above and beyond the call of duty on that fateful day but their real enemy wasn’t the fire, but catastrophic corporate governance and bad policy making spanning decades. This was an enemy that firefighters could not win against. The Grenfell Tower is now a monument and a constant reminder of the systemic corporate governance, policy and ethical failures that governed the Grenfell Tower and potentially many more housing estates in UK.



For a clear explanation on the concepts of MATERIALITY and MATERIAL ISSUES go to Part 1 Titanic Case Study.





1. Proper relations and communications with residents

Early warnings about fire safety standards at Grenfell Tower were ignored. A residents’ organisation, Grenfell Action Group (GAG), published a blog in which it highlighted major safety problems, including that the building had only one entrance and exit in case of a fire. Like in the Titanic story, early warnings had been given by residents to the relevant stakeholders about the unsafety of the Tower. Like in the Titanic case they were ignored. After the fire, the Grenfell Action Group, who posted numerous warnings in recent years about the very poor fire safety standards at Grenfell Tower said: ‘ALL OUR WARNINGS FELL ON DEAF EARS and we predicted that a catastrophe like this was inevitable and just a matter of time’.


2. High rise fire safety procedures & maintenance
Poor fire safety procedures were in place at Grenfell tower. Firefighting equipment at the Grenfell tower had not been checked for up to four years; on-site fire extinguishers had expired, and some had the word “condemned” written on them because they were so old. There was no sprinkler system at Grenfell Tower and residents never heard fire alarms going off. Emergency lighting needed in case of a fire was criticised as inadequate twelve years before the fire. There was insufficient mains water pressure for the hoses the fire service used and Thames Water had to be called to increase it on the night of the fire. A fire brigade high ladder did not arrive for 32 minutes, by which time the fire was out of control. Since the fire, the London Fire Brigade told BBC Newsnight that the first attendance procedure for tower fires has now been changed from four engines to five engines plus a high ladder unit.

Stay put policy. Common Sense must prevail.
KCTMO, who managed Grenfell Tower, instructed residents (on the advice of the fire brigade) to stay in their flat in case of a fire (“Our longstanding ‘stay put’ policy stays in force until you are told otherwise”) and stated that the front doors for each unit could survive a fire for up to 30 minutes. The standard advice for people to stay put until rescued relied on the assumption that construction standards such as concrete and fire-resistant doors would allow fire services to contain a fire within one or a few affected flats. However, at Grenfell the fire spread rapidly via the building’s flammable exterior cladding. Like in the Costa Concordia case, many of the Grenfell residents that listened to authority or followed establish procedures (stay in your cabins or stay inside your flats) would perish. Luckily in both cases many people disobeyed authority, used common sense and saved their lives.


3. Cutting costs on building materials and safety.  

When cutting costs is costing lives. Poor industry fire safety standards and building regulations at Grenfell Tower. The Grenfell Tower fire had been started by a faulty refrigerator in a flat on the 4th floor. Flames spread quickly up the exterior cladding made of a metal outer coating and an expanded polyethylene – plastic – core foam interior. Dr Roth Phylaktou, an expert in fire investigation, said: “The polyethylene in the cladding would have burnt as quickly as petrol.” In June 2017 it was stated the project team in charge of refurbishing the Tower chose cheaper cladding that saved the KCTMO £293,368, as it needed to cut costs. Grenfell Tower’s cladding was cheaper and less fire-resistant. Both the aluminium-polyethylene cladding and the PIR insulation plates failed fire safety tests conducted after the fire, according to the police. Many governance failures in business, industry and government happen due to cost cuttings that affect crucial components directly or indirectly, in the present or the future. These seemingly important cost cuttings often result in massive losses to property, the environment and human lives.


4. Proper construction industry fire safety standards and building regulations 

It is felt at the time of Grenfell that building regulations were weak and confused, allowing building firms to take advantage and cut costs using dangerous materials. Similar cladding containing highly flammable insulation material is believed to have been installed on thousands of other high-rise buildings in countries including Britain, France, the UAE and Australia.

In the 1970s Oscar winning disaster movie starring Paul Newman and Steve McQueen, the ‘Towering Inferno’, the owners of the new and tallest skyscraper in the world decide to cut costs on construction and use cheaper building materials, reducing building safety. The skyscraper goes up in flames on inauguration night, many die. Sounds familiar?

UK Building regulations are currently under review in the light of the fire due to concerns with the rules and their enforcement. The Independent Review of Building Regulations and Fire Safety of 2017 concluded that the entire building regulatory system as “not fit for purpose” and made interim recommendations for significant change.

After Grenfell, the government had decided not to ban all flammable cladding on buildings though the Royal Institute of British Architects, Grenfell survivors, building firms and fire safety experts favour an outright ban. In May 2018 the UK government announced that there will be a consultation on banning inflammable cladding on high-rise buildings, despite such review into the Grenfell tragedy not recommending such a move. Maybe this time common sense will prevail again.


5. Sustainable & Ethical Corporate Governance 

Similar to the Titanic and Costa Concordia cases, the lack of proper corporate values and ethics made the Grenfell Tower management company, KCTMO, focus on the wrong priorities. In July 2017, the Metropolitan Police issued a public notice to residents saying that they had “reasonable grounds” to suspect that both the Royal Borough of Kensington and Chelsea (RBKC) and the Kensington and Chelsea Tenant Management Organisation (KCTMO) “may have committed” manslaughter, corporate manslaughter, misconduct in public office and fire safety offences. Like in Titanic, bad policy making and regulations governing critical issues and safety were antiquated and behind the times. Only the right ethics and their proper application to governance would have made the people involved in decision making at RBKC and KCTMO to decide for what was right. Not for what was cheaper.



Like in Titanic and the Costa Concordia tragedies there’s now a Grenfell Tower Fire public inquiry. The inquiry is still ongoing and could last until 2020. But the Titanic, Costa Concordia and Grenfell tragedies must stand for something important. Their lessons for bettering future corporate and public governance and policy making are clear. If we do not change corporate cultures and mindsets to become better at anticipating critical events and outcomes and become more ethically sustainable in decision making, we will not have to wait long until the next Titanic leaves port. And for the dead yet another public inquiry on another tragedy will mean justice comes again too late.



I dedicate this article to the victims of Grenfell Tower Fire and their families and especially to Marco and Gloria, my Italian compatriots, two young architects in their 20s that moved to London and that lived in the Grenfell Tower. Marco’s family and friends have written a children’s book turning what happened into a fairy tale – but unlike real life, the story has a happy ending. To donate to the Grenfell Love Marco & Gloria Foundation click here.

For Part One of this case study, Titanic Click Here. For Part Two, Costa Concordia Click Here.

Additional Information
Grenfell Tower Fire: Who were the Victims

Grenfell Inquiry: What is happening?

On the Author

Nicolas De Santis is the CEO of Corporate Vision® and the President of Gold Mercury International, the global governance think tank and international award. A business theorist, author, consultant and entrepreneur, Nicolas is widely recognised as a visionary change agent, advising corporations, global brands, start-ups and governments on visionary governance, strategy, global branding, business model innovation, cultural alignment and the future direction of our world. De Santis advises international organisations, corporations and governments on national strategy, strategic visioning, cultural transformation, business model innovation & global brand strategy. As an internet entrepreneur, Nicolas De Santis was one of the founding management team of OPODO, the European online travel portal and of, the first digital global internet currency.