Imran Khan QC delivers closing statement on behalf of Behailu Kebede, arguing for the inquiry to find the fire was accidental and originated in his Hotpoint fridge freezer, while critiquing Whirlpool's attempts to deflect responsibility.
00:08:57 good morning everyone and welcome to today's hearing we're going to continue here in closing statements from there is core participants beginning with mr. Menon who represents mr. Kirby
00:09:10 Menon who represents mr. Kirby yes mr.
00:09:21 good morning truth justice and accountability those have been the demands of the bereaved and the survivors of the grenfell tower atrocity
00:09:32 survivors of the grenfell tower atrocity from day one but what do they mean in the context of a public inquiry and specifically what do they mean as far as the phase one terms of reference and
00:09:43 the phase one terms of reference and list of issues are concerned noting the distinction you have made mr. chairman between what happened to be considered in phase one and why it happened to be
00:09:54 in phase one and why it happened to be considered in phase two after six months of evidence it is clear that this distinction between what and why is easier said than done
00:10:05 easier said than done you were right to acknowledge at an early stage that you intended to retain a significant degree of flexibility in relation to the scope of the inquiries to phases indeed you have already heard
00:10:18 to phases indeed you have already heard much evidence that goes to the question of why
00:10:21 of why and you still await much evidence that goes to the question of what but none of this should delay in our submission your phase one findings and recommendations
00:10:32 phase one findings and recommendations we stress this because the inquiry is already way behind schedule your initial hope was to complete your phase one report by Easter of this year and given
00:10:45 report by Easter of this year and given you still have to consider interim recommendations hearings for which have recently must been postponed and may or may not be rescheduled and hold
00:10:56 may not be rescheduled and hold individual article two compliant inquests into the depths of each of those who died as a result of the fire before Phase two it is unlikely that phase two will commence before the
00:11:07 phase two will commence before the autumn of next year at the earliest and possibly not until 2020 in short your phase one report is urgent the bereaved
00:11:19 phase one report is urgent the bereaved and the survivors and the public at large need you to make the most robust and decisive factual findings and recommendations that you and on the evidence so that the criminal
00:11:32 and on the evidence so that the criminal and civil liability of those responsible for the Granville Tower atrocity can be determined by others as soon as possible nothing less with respect will do now
00:11:44 nothing less with respect will do now some of what I say today will inevitably touch on the why as well as the what as has been the case in the submissions you've already heard and will be the case in the submissions you hear after
00:11:55 case in the submissions you hear after me so having said that let's start at the beginning namely the cause and origin of the file we made a number of assertions about this in our opening statement one after
00:12:10 this in our opening statement one after the high leukerbad a heard the kitchen smoke alarm opened his kitchen door and saw smoke coming from behind his Hut point fridge/freezer he did the right thing from start to
00:12:22 he did the right thing from start to finish he shut the kitchen door woke up his flatmates woke up his neighbours on the fourth floor turned off the main electrical switch in his flat shut the
00:12:34 electrical switch in his flat shut the front door of his flat telephoned the fire brigade on 999 used the stairs to exit the building waited outside spoke to the firefighters when they arrived
00:12:46 to the firefighters when they arrived filmed the fire from outside on his mobile telephone and just a few hours later went to the police station and gave a full account about what happened to whatever the precise causal origin of
00:13:01 to whatever the precise causal origin of the fire in his kitchen it was entirely accidental three having heard the evidence the inquiry must set the record straight and unequivocally declared mr.
00:13:14 straight and unequivocally declared mr. cabaret there's no responsibility directly or indirectly for the outbreak of the fire in his kitchen it's spread and its fatal consequences since then a considerable amount of
00:13:27 since then a considerable amount of eyewitness audio video and expert evidence has been adduced and all of it without exception confirms the honesty and reliability
00:13:38 and reliability of what mr. cabaret has always said and confirms that he was indeed blameless for what happened there is the evidence of mr. cabaret himself and his flatmates
00:13:50 of mr. cabaret himself and his flatmates Elsa of a walkie and Alma skinfood there is the evidence of their fourth floor neighbors there is mr. kuberdas 999 call there is the evidence of the first
00:14:01 there is the evidence of the first responders charlie batter B Daniel brown john o'hanlan and nicholas barton there is the first responders thermal-imaging camera footage there is mr. Cobb a days
00:14:12 camera footage there is mr. Cobb a days mobile telephone and video footage and there are the photographs of the kitchen and its contents taken after the fire by the investigators and finally there is the expert evidence of dr. Glover and
00:14:25 the expert evidence of dr. Glover and professor Nick dead two things that mr. Kapadia did on the night deserve special mention one turning off the main
00:14:36 mention one turning off the main electrical switch in his flat before leaving
00:14:39 leaving if mr. cabana had not done this much of dr. Glover's analysis would have been difficult if not impossible if mr. kabaddi had not done this the fire could
00:14:51 kabaddi had not done this the fire could have tripped many possibly all of the circuit breakers in his flat dr. Glover would then have been unable to link the abnormal electrical event that caused
00:15:02 abnormal electrical event that caused the fire to circuit breaker number seven specifically in short mr. kuberdas quick thinking may dr. Glovis task as an electrical engineer considerably easier
00:15:14 electrical engineer considerably easier to filming the fire in his kitchen as it spread to the external facade this footage was taken by mr. Cobb a day on his mobile phone whilst he was standing
00:15:27 his mobile phone whilst he was standing outside Granville tower at ground level looking up it was given to the police just hours later it was heavily relied upon by the inquiries experts most
00:15:38 upon by the inquiries experts most notably professor torero professor Bisbee and dr. lay without it they and you mr. chairman would have been deprived of crucial video evidence of this most critical stage of the fires
00:15:50 this most critical stage of the fires development consequently we trust you will specifically recognize in your phase 1 report the importance of what mr. Kapadia did on the night and make the
00:16:02 Kapadia did on the night and make the following factual findings on cause and origin one the grenfell tao of fire began in the southeast area of the flat
00:16:13 began in the southeast area of the flat 16 kitchen - the fire was electrical in nature 3 the origin of the fire was in
00:16:24 nature 3 the origin of the fire was in the Hotpoint FF 175 the fridge freezer and for the cause of the fire was accidental we say that none of these
00:16:36 accidental we say that none of these factual findings are controversial there is no evidence suggesting anything to the contrary moreover until whirlpools closing submissions were circulated on
00:16:48 closing submissions were circulated on Thursday last week we were unaware that any core participant was arguing anything to the contrary so what exactly is whirlpool now saying 1 although the
00:17:02 is whirlpool now saying 1 although the inquiry can conclude that the fire began in or around the area of the hot point fridge freezer in the southeast corner of the kitchen and was caused accidentally it cannot conclude that the
00:17:15 accidentally it cannot conclude that the fire was electrical in nature or that it originated in the fridge freezer - as Professor Nick Dade said in her final report the cause of the fire remains
00:17:27 report the cause of the fire remains undetermined 3 dr. Glover's addendum report on the precise cause of the fire is flawed and based on incorrect
00:17:38 is flawed and based on incorrect assumptions for the exemplar fridge freezer that dr. Glover compared with mr. kuberdas fridge freezer had some
00:17:49 mr. kuberdas fridge freezer had some different component parts therefore dr. Glover was not comparing like with like 5 there is no evidence that points uniquely to the fridge freezer 6
00:18:02 uniquely to the fridge freezer 6 potentially significant evidence may have been shoveled from the kitchen into the hallway and down the lift shaft during the original fire scene investigation 7 unknown materials in the
00:18:14 investigation 7 unknown materials in the southeast corner of the kitchen remain unidentified and unexamined 8 burn patterns to the laminate flooring would have been identical if the fridge freezer had been
00:18:26 identical if the fridge freezer had been attacked by fire and therefore do not assist in determining the origin or seat of the fire 9 the fire may have started not electrically by somebody throwing
00:18:40 not electrically by somebody throwing something perhaps a burning cigarette into the kitchen through the open window that ignited unknown combusted materials in the corner now our response to
00:18:52 in the corner now our response to whirlpool submissions is as follows what assertion by whirlpool in its closing submissions is not evidence as far as we are aware whirlpool is neither served
00:19:05 are aware whirlpool is neither served any expert evidence to counter the evidence and opinions of dr. Glover and professor Nick Dade nor apply to the inquiry for permission to serve such evidence
00:19:15 evidence whirlpool did serve a preliminary port report prepared by a company called exponent in January 2018 long before dr. Glover was instructed but that report
00:19:27 Glover was instructed but that report says little and takes matters no further and nothing since then - the most important factual finding on cause and origin that mr. cuvee day wants you to
00:19:39 origin that mr. cuvee day wants you to make is that the cause of the fire was accidental on that narrow issue there is no conflict between mr. kuberdas and whirlpool 3 however one of the
00:19:52 and whirlpool 3 however one of the primary objectives of the inquiry is ensuring that a similar catastrophe never happens again if the fire at grenfell Tower that killed 72 people did
00:20:04 grenfell Tower that killed 72 people did in fact start in a faulty fridge freezer then you must find accordingly so that as a society we can try and regulate in the interest of Public Safety and prove similar fires in the future for
00:20:17 similar fires in the future for according to home office statistics there were over 27,000 accidental dwelling fires in England between April 2016 and March 2017 about 16% of those
00:20:32 2016 and March 2017 about 16% of those fires in other words over 4,000 360 fires were caused by faulty electrical appliances and leads between 2010 and
00:20:43 appliances and leads between 2010 and 2016 there were over 300 domestic fires in England annually that were caused by faulty fridges and freezers all this information is in the public domain
00:20:55 information is in the public domain Whirlpool itself has received five prior reports of fire involving the Hotpoint FF 175 BPM or one of which involved a fridge filles
00:21:07 one of which involved a fridge filles freezer manufactured in the same month and year as mr. kuberdas fridge freezer v an issue of growing public concern is the plastic rear casing on many of the
00:21:20 the plastic rear casing on many of the United Kingdom's most popular fridges and freezers mr. kuberdas Hotpoint fridge freezer had such a plastic rear casing the London Fire Brigade has been
00:21:31 casing the London Fire Brigade has been raising concern about this issue for years as has the consumer rights group which unfortunately the government has thus far failed to regulate to ensure that all fridges and freezers have
00:21:43 that all fridges and freezers have protective metal rear cases dr. Glover told you mr. chairman that in the United States the rear casing of fridges and freezers must be made of a metallic steel this is a matter to which
00:21:56 metallic steel this is a matter to which we will return in due course when you consider interim recommendations arising from phase 1 6 although professor Nick day did state in her final report that
00:22:09 day did state in her final report that the cause of the fire remains undetermined she clearly changed her mind
00:22:14 mind by the time she gave evidence having heard dr. Glover's evidence the day before specifically she agreed with dr. Glover that the fire was electrical in nature and
00:22:26 nature and in the Hotpoint fridge/freezer seven although potentially significant evidence may have been lost during the original fire scene investigation there
00:22:37 original fire scene investigation there is not a shred of evidence that the fire was caused by a non electrical event involving for example a cigarette or a candle or incense or oil 8 whirlpool in
00:22:50 candle or incense or oil 8 whirlpool in its closing submissions has completely ignored the evidence in respect of circuit breaker number seven tripping this is clear evidence pointed to an
00:23:01 this is clear evidence pointed to an electrical fire and specifically to the hot point fridge/freezer nine burn patters to the laminate flooring would not have been identical if the fire had
00:23:12 not have been identical if the fire had begun elsewhere in the southeast corner of the kitchen and then attacked the fridge freezer the area around sorry the area under the fridge freezer was clearly subjected to
00:23:23 fridge freezer was clearly subjected to much more heat than the surrounding areas of laminate flooring worth hence the very different burn patterns 10 whirlpool in its closing submissions has
00:23:34 whirlpool in its closing submissions has completely ignored the evidence that all the other electrical appliances in both the southeast and northeast air Northeast areas of the kitchen can be discounted as being seats of origin
00:23:46 discounted as being seats of origin namely the cooker the broken freezer the small fridge and the Ethiopian hot plate the latter three were not even plugged in 11 it is hardly dr. Glover's fault
00:24:01 in 11 it is hardly dr. Glover's fault that the exemplar fridge freezer provided to the Metropolitan Police Service had different component parts to mr. kuberdas fridge freezer it was whirlpool that provided the exemplar widen whirlpool provide the
00:24:14 exemplar widen whirlpool provide the Metropolitan Police Service with an exemplar that had the identical component parts as far as we are aware whirlpool has provided no explanation for this anomaly 12 as far as the theory
00:24:28 for this anomaly 12 as far as the theory of the fire having started as a result of something thrown through the open window is concerned this is pure speculation and desperate to put it politely
00:24:39 politely there is no evidence and support it would have been impossible for a cigarette or some other mystery item to have been launched from ground level four floors down and it is equally
00:24:51 four floors down and it is equally impossible to imagine how a cigarette or some other mystery item discarded from a flat above could have miraculously entered the kitchen through the open window let alone set anything in the
00:25:03 window let alone set anything in the vicinity alight and finally 13 I'm afraid mr. chairman that whirlpools closing submissions are a transparent
00:25:14 closing submissions are a transparent attempt by a multinational corporation with billions in assets to try and avoid liability and minimize reputational damage and financial loss it is the same
00:25:26 damage and financial loss it is the same strategy that whirlpool used during the inquest in 2012 into the deaths of five members of the kueh family that I mentioned during my opening statement to
00:25:38 mentioned during my opening statement to try and deflect attention away in that tragic case from a whirlpool freezer that failed electrically and caught fire you may like to know mr. chairman the coroner in that case roundly rejected
00:25:51 coroner in that case roundly rejected whirlpools submissions in short there is more than sufficient evidence for you to conclude that the fire was electrical in nature and originated in mr. kuberdas
00:26:04 nature and originated in mr. kuberdas Hotpoint fridge freezer in addition to concluding that the cause of the fire was accidental as far as the precise cause of the electrical fault that
00:26:15 cause of the electrical fault that ignited the fire is concerned we accept that is more complicated in his addendum report dr. Glover concludes that the probable cause was a poor crimp
00:26:26 probable cause was a poor crimp connection that caused overheating and arc damage to the run capacitor wires a short circuit to circuit breaker number seven and a subsequent short circuit to
00:26:39 seven and a subsequent short circuit to the residual current circuit breaker Professor Nick died whilst conceding that she is not an electrical expert was not in full agreement as to the precise cause she did not clarify the
00:26:52 cause she did not clarify the any further it's a matter for you mr. chairman whether or not you make a factual finding as to the precise cause suffice to say that you do have the necessary evidence if you wish to make
00:27:04 necessary evidence if you wish to make such a finding ultimately you may think that the precise cause is of less importance from the perspective of the public interest in public safety than the question of how an ordinary domestic
00:27:16 the question of how an ordinary domestic fire that happens every day in the United Kingdom and is entirely foreseeable managed to penetrate the exterior facade of the building and spread with such ease speed and ferocity
00:27:31 turning then to the more general matters about what happened beyond the confines of flat 16 the extent to which grant felt are complied with the requirements
00:27:43 felt are complied with the requirements of the relevant legislation and the response of the firefighters unsurprisingly some of these matters are simple and straightforward and others are far more complex and nuanced and
00:27:56 are far more complex and nuanced and other counsel for the bereaved and the survivors have addressed you on flame and smoke spread once the cladding and insulation caught fire and how a cladding the insulation the architectural crown at the top of the
00:28:08 architectural crown at the top of the building the window installations the doors and the ventilation system all played their part in flame and smoke spread I don't wish to be repetitious
00:28:20 spread I don't wish to be repetitious and consequently have nothing to add on compliance I'll be brief as well as this too has been addressed by others at length Grenville tower as refurbished
00:28:32 length Grenville tower as refurbished was non-compliant in multiple respects with the building regulations and approved document being regardless of how unfit for purpose and impenetrable
00:28:44 how unfit for purpose and impenetrable those regulations might be there is simply no rational basis for concluding there was compliance this is not a borderline case this is a case of
00:28:56 borderline case this is a case of flagrant and extensive non-compliance the evidence of Professor torero professor Bisbee and MOU importantly dr. Lane is unequivocal on
00:29:07 importantly dr. Lane is unequivocal on this specifically there is no evidence whatsoever to counter dr. lanes important conclusion that Grenfell tower should never have been handed over to
00:29:18 should never have been handed over to its residents and occupied with such combustible rainscreen cladding system given the state of the state put policy consequently it is unthinkable mr.
00:29:29 consequently it is unthinkable mr. chairman that you will conclude Grenfell tower was anything other than non-compliant and it is equally unthinkable that you will conclude you need to delay until the end of phase two
00:29:43 need to delay until the end of phase two before making definitive findings our non-compliance this fundamental issue needs to be decided as soon as possible so that we can start to get to the
00:29:54 so that we can start to get to the bottom of why and how this was ever allowed to happen what about the response of the firefighters I'm just
00:30:07 response of the firefighters I'm just going to pause for a minute
00:30:46 when you're ready thank you what about the response of the firefighters having read and heard the closing submissions of other Corps participants I'm afraid I
00:30:59 of other Corps participants I'm afraid I I do wish to speak to this issue at some length as it is in our submission far more complex and far more nuanced than some are suggesting it is very easy with
00:31:13 some are suggesting it is very easy with the benefit of hindsight gained from all the evidence served in phase one and adduced in the relative comfort of Holborn bars I appreciate that is a
00:31:24 Holborn bars I appreciate that is a controversial statement to serve for lawyers and judges who have almost certainly never been in a towering inferno to pass sweeping over simplistic
00:31:37 inferno to pass sweeping over simplistic judgments about what the firefighters working under the most extreme conditions did or did not do on the night what we need mr. chairman from you
00:31:48 night what we need mr. chairman from you is a fair balanced and reasoned assessment that recognizes just how difficult it is to predict with any degree of certainty or precision what
00:32:02 degree of certainty or precision what might have happened in one hypothetical situation or another on the night if different decisions had been made and different actions had been taken for
00:32:13 different actions had been taken for example if there had been better contingency planning as there undoubtedly should have been or if statehood had been abandoned earlier as it undoubtedly should have been we are
00:32:26 it undoubtedly should have been we are acutely conscious that the issue of the firefighters is a contentious one amongst the bereaved and survivors you would have gleaned from their evidence
00:32:37 would have gleaned from their evidence that whereas there is unity on other matters there are a variety of differing views as to the response of the firefighters on the night some believe
00:32:48 firefighters on the night some believe the firefighters are heroes who did everything they possibly could in an impossible situation some believe that fundamental errors were made that contributed to the lives
00:32:59 were made that contributed to the lives of some being lost and some are on the spectrum somewhere in between so this is troubled water to navigate but navigated
00:33:10 troubled water to navigate but navigated we must with great care and fairness were mistakes made on the night yes of course mistakes were made on the night how could mistakes not have been made
00:33:22 how could mistakes not have been made given the nature of the building and the fire should lessons be learned from those mistakes yes of course lessons must be learned from those mistakes it was most unfortunate that Danny cotton
00:33:36 was most unfortunate that Danny cotton the commissioner when praising the firefighters for all their efforts which she was absolutely right to do by the way added that she would not go back and change anything
00:33:47 would not go back and change anything the London Fire Brigade did on the night that was not only deeply insulting to the bereaved and survivors but also indicative of an inability on her part
00:33:59 indicative of an inability on her part and perhaps on the part of the London Fire Brigade as an institution to appreciate even with the benefit of hindsight the London Fire Brigades institutional failings and deficiencies
00:34:11 institutional failings and deficiencies pre-ground fell as identified by the Fire Brigades Union and others in their closing submissions however mr. chairman if the primary focus of your phase 1
00:34:24 if the primary focus of your phase 1 reports degenerates into a wholesale attack on the response of the firefighters institutionally or individually that in any way weakens or
00:34:38 individually that in any way weakens or detracts from your all-important condemnation of the transformation of Grenfell tower during its refurbishment into a combustible non-compliant deathtrap unsafe for human occupation
00:34:50 deathtrap unsafe for human occupation then that would be perverse and would play straight into the hands of those statutory and corporate core purpose who in reality their full responsibility for
00:35:02 in reality their full responsibility for the spread of the fire the failure of the building and the dreadful consequences that followed that would not be and I quote a fearless reckoning with what
00:35:13 quote a fearless reckoning with what went wrong and what must be different in future the firefighters on the ground at Granville Tower were part of the solution not part of the problem whatever mistakes they made they must
00:35:26 whatever mistakes they made they must not be scapegoated for not knowing on the night what the inquiries experts have concluded after they and teams of scientists and engineers have spent
00:35:37 scientists and engineers have spent literally months studying the remains of the building and its contents conducting experiments and tests reading the evidence of the firefighters the bereaved and the survivors and
00:35:48 bereaved and the survivors and investigating what exactly happened at Granville Tower on the night of the fire if the firefighters on the ground at Granville Tower are unfairly scapegoated the only beneficiaries will be the
00:36:00 the only beneficiaries will be the aforementioned statutory and corporate corpus appoints that is neither justice nor accountability now there are seven specific issues we wish to discuss about
00:36:12 specific issues we wish to discuss about firefighting in general and the response of the firefighters on the night the first is this you cannot ignore mr. chairman the wider context that allowed
00:36:24 chairman the wider context that allowed the Granville fire to happen namely the systemic deregulation of fire safety in this country under successive governments since the Thatcher era or
00:36:37 governments since the Thatcher era or the draconian cuts of over 30 percent to central funding of Fire and Rescue Services under austerity laws and regulations have been weakened in the
00:36:48 regulations have been weakened in the name of cutting red tape all for the benefit of the construction industry government-funded fire research has virtually ceased fire safety standards have dropped and the lessons of
00:37:00 have dropped and the lessons of countless inquiries in quests and investigations have been ignored by the state as far as cuts are concerned in London alone since 2010 10 fire stations
00:37:12 London alone since 2010 10 fire stations have been closed 27 fire engines have been scrapped and over 600 firefighters have lost their jobs this is madness we are one of the richest countries in the world as a
00:37:24 richest countries in the world as a society there is no point in producing endless reports unless we reverse fire safety deregulation by reregulate unless we reverse cuts by substantially
00:37:37 we reverse cuts by substantially investing in the fire and rescue services and ensuring that they have the very best resources and equipment they need to fight fire and save life in the 21st century as a society we must
00:37:50 21st century as a society we must prioritize people and safety over profit we have the money the question is how we decide to spend it the second issue is
00:38:03 decide to spend it the second issue is this when assessing the performance of the firefighters on the night mr. chairman you need to make a clear distinction between the institution of
00:38:14 distinction between the institution of the London Fire Brigade and those in senior management positions on the one hand and the rank-and-file firefighters on the other the rank and file including
00:38:25 on the other the rank and file including watch managers like Mike dowdy are not responsible for the inadequacy of their training on high-rise fires combustible cladding compartment ation breach stay put and evacuation the rank and file are
00:38:38 put and evacuation the rank and file are not responsible for the inadequacy of contingency planning the rank and file are not responsible for the non-existence of a high-rise evacuation strategy the rank and file are not
00:38:49 strategy the rank and file are not responsible for poor quality equipment in particular unreliable communication equipment the third issue is this council - the inquiry put - a number of
00:39:02 council - the inquiry put - a number of senior officers that firefighters should always expect the unexpected a fair point they should but what is the unexpected mean what does it encompass
00:39:16 unexpected mean what does it encompass surely the unexpected must be reasonably foreseeable or should the firefighters expect the unforeseeable to forget Danny Cotton's absurd example of a space
00:39:28 Cotton's absurd example of a space shuttle landing on the shard let's let's consider a real example should the New York firefighters have expected two airplanes to fly into the World Trade Center on 9/11 and had a
00:39:40 the World Trade Center on 9/11 and had a specific contingency plan for such an event but they cannot be right that cannot be proportionate the need to plan specifically for a major disaster of a kind that has happened before and is
00:39:54 kind that has happened before and is therefore foreseeable is one thing the need to plan specifically for an unforeseeable event that no firefighter in London has experienced or contemplated is another thing altogether
00:40:06 contemplated is another thing altogether so what was reasonably foreseeable in terms of a high-rise residential fire in London in June 2017 what cladding fire was reasonably
00:40:18 what cladding fire was reasonably foreseeable to firefighters it had happened before notably at knowsley Heights in Liverpool in April 1991 the first high-rise cladding fire in the UK
00:40:29 first high-rise cladding fire in the UK where the fire spread upward and vertically at Garnica Court in Irvin Scotland in June 1999 where the fire also spread upward and vertically and of course at lacan all
00:40:42 vertically and of course at lacan all house in South London in July 2009 yes July 2009 where there was both cladding fire spread and internal fire spread through combustible false
00:40:54 spread through combustible false ceilings in between floors that undermine compartment ation what else what compartment ation breach was also reasonably foreseeable to firefighters it do it happened before notably had
00:41:07 it do it happened before notably had gone a court at Lac an old house and most recently at Shepherd's court in Shepherds Bush in August 2016 where the fire was extinguished fire
00:41:19 where the fire was extinguished fire behaving unusually was also reasonably foreseeable to firefighters what about lateral fire spread and downward fire spread to the external
00:41:30 downward fire spread to the external cladding well professor Toreros evidence is significant on this point he stated that a lateral fire spread and downward fire spread are rare in high-rise
00:41:41 fire spread are rare in high-rise cladding fires usually the fire spreads upwards and vertically and then proceeds to decay and eventually extinguish once it reaches the top of the building Granville Tower was clearly different in
00:41:53 Granville Tower was clearly different in large part because of the design and combust ability of its unique architectural crown what about total building failure well total building failure was
00:42:06 well total building failure was certainly not reasonably foreseeable to the rank-and-file firefighters pre Grenfell it played no part at all in any training they'd received about high-rise
00:42:17 training they'd received about high-rise firefighting what about the London Fire Brigade as an institution pre Granville that is a tough one now even if it was a foreseeable event for the London Fire
00:42:29 foreseeable event for the London Fire Brigade it was clearly not in fact foreseen on the nut now when considering that issue in other words the reasonable foreseeability of total building failure
00:42:40 foreseeability of total building failure to the London Fire Brigade as an institution you may wish to bear in mind mr. chairman that none of the high-rise fires in the UK that I've already mentioned or others that were mentioned
00:42:51 mentioned or others that were mentioned in the course of the evidence resulted in total building failure not one of them furthermore none of the recent well-known international high-rise fires
00:43:04 well-known international high-rise fires resulted in total building failure for example the memo's fire in Roubaix France in May 2012 the La Crosse fire in Melbourne
00:43:15 the La Crosse fire in Melbourne Australia in November 2014 the marina torch fire in Dubai in February 2015 and the address downtown hotel fire in Dubai
00:43:28 the address downtown hotel fire in Dubai in December 2015 there is some information online to suggest that there may have been high-rise fires in China Iran and Azerbaijan that resulted in
00:43:42 Iran and Azerbaijan that resulted in total building failure but as Professor torero stated there is very little detailed publicly and there information about most international fighters even a leading internationally
00:43:54 fighters even a leading internationally renowned fire expert like Professor torero does not apparently have access to the necessary information in short despite the undoubted similarities
00:44:05 despite the undoubted similarities between the grand felt our fire and previous high-rise fires in the UK and around the world and the undoubted lessons that could and should have been loan learnt from those previous fires
00:44:18 loan learnt from those previous fires the grand felt our fire was unprecedented in the sense that it involved total building failure whereas none of the other high-rise fires did
00:44:29 none of the other high-rise fires did consequently it is hardly surprising that many prominent and experienced fire investigators have publicly stated that they have never seen a high-rise building completely consumed by fire
00:44:42 building completely consumed by fire like Grenfell tower was it is important to recognize that total building failure is not simply a question of scale a large cladding fire that causes a
00:44:55 large cladding fire that causes a significant number of compartment ation breaches and behaves unusually is not tantamount to total building failure total building failure involves the failure of all or most of the fire
00:45:08 failure of all or most of the fire safety features in the building such that the fire becomes unextinguishable at Grenfell tower everything failed with the exception of the concrete core
00:45:19 the exception of the concrete core structure of the building for completeness sake I should mention the one fire that did involve total building failure although the building in
00:45:31 failure although the building in question was neither high-rise nor residential and the walls and roof were made of plastic as opposed to aluminium with a polyethylene core namely the fire
00:45:43 with a polyethylene core namely the fire at the Summerland leisure center on the Isle of Man in August 1973 you know about this I'm sure mr. chairman Summerland was a huge indoor holiday park wrapped
00:45:55 was a huge indoor holiday park wrapped in a combustible acrylic material without any sprinkler system when it caught fire from a discarded the flames spread quickly once the flames became visible to the
00:46:06 flames became visible to the approximately 3,000 people inside the building at the time there was mass panic crushing and trampling as the crowds headed for the exits but the fire was too ferocious it killed 50 and
00:46:17 was too ferocious it killed 50 and seriously injured another 80 although it led in the short-term to the strengthening of outdated building regulations in the UK the lessons were not learnt by the powers that be by the
00:46:29 not learnt by the powers that be by the early 1980s the deregulation of fire safety was in full swing the fourth issue is a brief one namely the
00:46:41 issue is a brief one namely the familiarization visits others have already addressed to you on section 7 2d as far as Grenfell is concerned the familiarization visits were clearly deficient however and it's only a small
00:46:55 deficient however and it's only a small point but I do think it's important to make we shouldn't exaggerate what a firefighter conducting a perfect familiarization visit would have been able to discover even if a scientist or
00:47:08 able to discover even if a scientist or an engineer like Professor torero or doctor Lang had visited Renville tower on the 13th of June 2017 and spent a few hours familiarizing themselves with the building they would not have known that
00:47:20 building they would not have known that it was a deathtrap wrapped in highly combustible cladding or that it had a number of other dangerous design characteristics that accelerated the speed of fire spread they would have seen the cladding but
00:47:33 they would have seen the cladding but would not have known without research and testing how combustible it was they would have noted the ventilation system that doors the window installations the single stairs the absence of sprinklers
00:47:45 single stairs the absence of sprinklers in the absence of a central tannoy or alarm system but would not have known the impact of any of these features in the event of a fire they would have obtained general insights about the building but the extent to which such
00:47:58 building but the extent to which such insights would have assisted in fighting a fire of the GNAT nature and magnitude of the Grenfell tower fire is highly debatable the fifth issue is stay put at
00:48:10 debatable the fifth issue is stay put at Granville
00:48:12 Granville the starting point is of course that there never should have been a state board policy at Grenville tower in the first place given the cladding system and the fact
00:48:25 given the cladding system and the fact that the refurbished building should not have even have been occupied but this is the fault of those who refurbished the building not the London Fire Brigade
00:48:37 however given there was a State Board policy when should it have been abandoned without the benefit of hindsight now dr. lang was extremely
00:48:51 hindsight now dr. lang was extremely fair about this recognizing the dangers of attributing what we now know to what the firefighters could actually see at different times on the night and what
00:49:04 different times on the night and what Mike Dowd and the initial incident commander actually knew at different times standing outside the building consequently even though the fire had
00:49:15 consequently even though the fire had spread from inside the flat 616 kitchen to the external facade by about 108 a.m. begun to climb vertically by about 113 air and breached compartment ation by
00:49:28 air and breached compartment ation by about 1:15 a.m. dr. Lane was of the view that the fire was still localized and there was no need for the firefighters to think the fire could not potentially
00:49:39 to think the fire could not potentially be mitigated however once it continued to climb and in particular went beyond 11th floor and then eventually reached the top of the building by about 126
00:49:50 the top of the building by about 126 a.m. the building design condition for stay-put
00:49:54 stay-put had failed substantially in other words after around 126 a.m. stay-put should have been abandoned and an evacuation of the building organized we agree by about
00:50:07 the building organized we agree by about 126 a.m. notwithstanding the fire had yet to spread laterally Mike Dowden should have realized there was a real
00:50:18 should have realized there was a real risk of multiple compartment reaches across multiple floors whatever he heard or didn't hear on his radio
00:50:28 from what he himself could see happening to the east face of the building or at the very least should have made inquiries with the bridgehead over the
00:50:39 inquiries with the bridgehead over the radio as to what firefighters and residents inside the building was saying about internal fire and smoke spread however given dr. lanes cogent reasoning
00:50:51 however given dr. lanes cogent reasoning we do not believe you should make a factual finding that stay put should have been abandoned earlier than 126 a.m. as others have suggested the fact
00:51:02 a.m. as others have suggested the fact that Mike Dowd deployed a covering jet externally and ordered a more aggressive hydraulic pump by about 1:15 a.m. does not mean that he had already concluded
00:51:13 not mean that he had already concluded that defend in place on which they put depends was no longer viable throughout the building the mere fact that he recognized that he was fighting an external fire of substance does not mean
00:51:25 external fire of substance does not mean he should have ordered the immediate evacuation of the building nobody amongst the experts is suggesting that one final note on this issue this may
00:51:37 one final note on this issue this may not be popular with Sun but I have a great deal of sympathy for Mike doubt it's not his fault that the building behaved as it did
00:51:48 that the building behaved as it did after the fire spread beyond its compartment of origin it's not his fault that he was inadequately trained to be an incident commander for a fire of this nature or magnitude it's not his fault
00:52:00 nature or magnitude it's not his fault that the London Fire Brigade failed to replace him with a more senior and experienced incident commander much sooner than they in fact did it is not his fault
00:52:10 his fault there was no London Fire Brigade evacuation strategy in the event of stay put no longer being viable as Mike Dowden acknowledged when he gave evidence he was overwhelmed on the night I trust mr. chairman you will not make
00:52:24 I trust mr. chairman you will not make him the sacrificial lamb the sixth issue is evacuation I don't want to spend too long in evacuation because the evidence as to how a mass
00:52:35 because the evidence as to how a mass evacuation of the building after about 126 a.m. would have been organized and implemented how long it would have taken and what practical difficulties and
00:52:46 and what practical difficulties and environmental complications would likely have arisen is thin indeed at present I trust you agree that it will be wrong to speculate and make factual findings as
00:52:58 speculate and make factual findings as to what might have happened without the most careful consideration of all the evidence and all the likely variables that might have affected a mass
00:53:09 that might have affected a mass evacuation of the building as yet you have no sophisticated computer modeling on how a hypothetical evacuation would have worked in practice I assume that
00:53:22 have worked in practice I assume that the inquiries expert professor Galia from whom we have yet to hear will be doing an in-depth report on evacuation modeling for phase 2 all you have at the moment is the evidence of
00:53:34 have at the moment is the evidence of Professor purser the inquiries expert on toxicology who estimated that the ideal nominal evacuation time of all 293 occupants of the building to the lobby
00:53:46 occupants of the building to the lobby was 7 minutes if they all suddenly went into the stairs simultaneously which obviously wouldn't have happened in his report he qualifies that estimate by
00:53:57 report he qualifies that estimate by adding that given the presence of slower more elderly occupants and young children and the need to assist those with limited mobility a better estimate was about 15 minutes now to be fair to
00:54:09 was about 15 minutes now to be fair to Professor purser he never suggested that his calculations were particularly scientific and they clearly were not they were based on the fact that it took him 3 and a half minutes to descend the
00:54:21 him 3 and a half minutes to descend the stairs from top to bottom when he visited the site the dimensions of the stairs and his opinion as to the likely standing density per square meter on the stairs he was frank that his figures
00:54:35 stairs he was frank that his figures required a scenario that was in fact impossible at Grenville tower namely alerting all those present in the building to evacuate simultaneous by means of a general alarm system in
00:54:46 by means of a general alarm system in the common areas furthermore he did not consider a number of other obvious variables that would have slowed down any hypothetical evacuation such as the
00:54:57 any hypothetical evacuation such as the inevitable presence of firefighters under BA ascending the stairs in large numbers to assist with the evacuation and the inevitable impact of fear panic noise disorientation and smoke
00:55:11 noise disorientation and smoke inhalation on those evacuating in the circumstances you cannot possibly at present mr. chairman put a figure on how long a hypothetical evaluation evacuation would have taken or reach any
00:55:24 evacuation would have taken or reach any non speculative conclusions as to how many of those who died in the fire might have survived if statehood had been abandoned earlier there is no alternative I'm afraid but to defer your
00:55:37 alternative I'm afraid but to defer your assessment in respect of this hypothetical evacuation until Phase two the seventh and final issue is the future of stay put in a sense this is a
00:55:52 future of stay put in a sense this is a largely academic issue the reality is but the next time there is a fire and a high-rise residential building in the UK and sadly there will be a next time
00:56:03 and sadly there will be a next time sooner rather than later given the sheer number of tower blocks with similar clatter most residents will evacuate as soon as they find out about
00:56:14 evacuate as soon as they find out about the fire regardless of whether the building as a state board policy and regardless of the extent of any compartment ation breach or external fire spread for the foreseeable future the memory of what happened at Granville
00:56:27 the memory of what happened at Granville will drive residents to get out and stay out
00:56:32 out nevertheless given your remit includes making recommendations so that a similar catastrophe never happens again you're going to have to engage with stay put
00:56:44 going to have to engage with stay put more generally so should stay put be consigned to the dustbin of history but should it be replaced in all high-rise residential buildings with a
00:56:55 high-rise residential buildings with a policy of get out and stay out whenever there is a fire of any nature I don't want to labor the point was the Chairman but in a safe compliant high-rise
00:57:07 but in a safe compliant high-rise building stay-put has an inherent logic however counterintuitive it may be it works it saves lives and it has been doing so for decades not just in this
00:57:20 doing so for decades not just in this country but internationally in the vast majority of high-rise fires there is either no compartment ation breach or very limited compartment ation breach confined to a localized sector of the
00:57:32 confined to a localized sector of the building to evacuate the entire building in such circumstances is not only unnecessary but can also carry its own dangers in terms of promoting panic and chaos and exposing residents to smoke
00:57:45 chaos and exposing residents to smoke inhalation and injury that they would not otherwise face consequently getting rid of stay put altogether because it should never have been in force at
00:57:56 should never have been in force at Grenfell post refurbishment we're in our view be throwing the baby out with the bathwater so to speak what we need is a more reasoned approach involving a
00:58:08 more reasoned approach involving a proper review and risk assessment of every tower block its fire safety features and the viability of a stay put policy given the building's design carried out by a suitably qualified
00:58:20 carried out by a suitably qualified person
00:58:21 person and despite stay put being a principle of building construction firefighters have to be properly trained in how stay put applies how to identify when it is
00:58:34 put applies how to identify when it is no longer viable and how to facilitate the evacuation of different types of tower blocks depending on their design and fire safety features in conclusion
00:58:49 and fire safety features in conclusion mr. chairman Friday is the 18-month anniversary of the fire so far there have been no prosecutions and no
00:59:01 there have been no prosecutions and no bans there's been a lot of talk and very little action throughout the bereaved and the survivors including the hey Luca
00:59:13 and the survivors including the hey Luca bad eh who I represent have shown great patience great integrity and great courage despite all the trauma despite
00:59:26 courage despite all the trauma despite all the undoubted rage and despite the hardship that now they need you mr. chairman to be bold and brave - are you
00:59:39 chairman to be bold and brave - are you going to challenge vested interests are you going to expose corporate wrongdoing are you going to recognize how austerity destroys lives are you going to demand
00:59:53 destroys lives are you going to demand the re-regulation of fire safety are you going to speak truth to real power in this country or are you going to blame the working men
01:00:06 are you going to blame the working men and women who risk their lives every day and did their very best on the night but were unable to fight a fire that could not be fought the time is come please
01:00:20 not be fought the time is come please mr. chairman use your power wisely and do the right thing thank you thank you very much mr. well the next danger is
01:00:35 very much mr. well the next danger is coming from a representative of the group known as G 11 I think it might be sensible to have a short break at this point so we can rearrange things and then I will continue I'm going to say
01:00:47 then I will continue I'm going to say that five fast enough please
01:15:34 no mr. Thomas you'll get into addresses next I think I am yes Thank You mr. chairman the one thing that you and I can probably agree on is that you
01:15:45 can probably agree on is that you haven't heard of sign it I'm sorry I didn't get you to sign up I do spill it s I n AI t No okay
01:15:57 s I n AI t No okay well let me tell you about a sign up in 2015 the local population of sign up from a census indicated the population
01:16:08 from a census indicated the population was 25,000 signer is a small picturesque fishing village with white sand beaches crystal-clear waters and it's located on
01:16:21 crystal-clear waters and it's located on the South China Sea in the northern province of the Philippines it's about 441 kilometres from Manila its main commodity is garlic hence it's
01:16:36 its main commodity is garlic hence it's known as the garlic center of the north its inhabitants are known for their building skills and shipping the other interesting thing about Earth sign up is
01:16:48 interesting thing about Earth sign up is that houses the miraculous statue of the Black Nazarene or el santo cristo Milagro saw locally known as a pope
01:17:02 Milagro saw locally known as a pope Lackey in the year 1620 no chol fishermen from signer and another nearby village called burdock found a black box
01:17:15 village called burdock found a black box floated in the sea with two statues one of the Blessed Virgin Mary the other of the Black Nazarene and according to legend sir fishermen
01:17:28 and according to legend sir fishermen from seiner were mysteriously unable to meet the statue of the Blessed Mary whereas fishermen from burdock were unable to leave the statue of the blackness
01:17:40 so each group of fishermen carried the respective statues that they were able to carry back to their local villagers
01:17:51 to carry back to their local villagers the Black Nazarene became the patron saint of sign up apparently in 1656 an epidemic was raging through
01:18:03 in 1656 an epidemic was raging through seiner and it was said that through the devotion of the faithful many people got cured sir just over 72 years ago three
01:18:19 cured sir just over 72 years ago three weeks ago on the 24th of November 1946 my client mr. le pedo Bonifacio was born
01:18:30 my client mr. le pedo Bonifacio was born in silent at the time the population was 13,000 on the 14th of June 2017 mr. Bonifacio was the last person taken
01:18:43 mr. Bonifacio was the last person taken out of the Grenville Tower at 8:08 a.m. Mr Bonifacio resided in flat 83 which is on the 11th floor before the
01:18:55 on the 11th floor before the refurbishment it was the 8th floor where he lived of his wife Rosetta for 36 years Rosetta is here today because of disability he was
01:19:06 today because of disability he was unable to self evacuate that night his daughter-in-law made four frantic 999 calls on his behalf throughout the night
01:19:17 calls on his behalf throughout the night into daylight he moved backwards and forth from the windows of one of the bedrooms waving a towel waiting to be seen and to be rescued with flames
01:19:29 seen and to be rescued with flames engulfed in the entire building in the early hours of the 14th of June Mr Bonifacio prepared to die like many of the other residents in Granville
01:19:43 his personal chronology of waiting to dyes heroin he believed his fate was sealed the image of mr. Bonifacio waving at the window was picked up by a helluva
01:19:55 at the window was picked up by a helluva touch and indeed news footage in which he appears to be a poignant figure in desperation trapped inside Grenfell as
01:20:06 desperation trapped inside Grenfell as dawn was breaking sir mr. Bonifacio's oral testimony would have provided this
01:20:18 oral testimony would have provided this inquiry with a unique powerful an invaluable perspective what is unique about mr. Bonifacio survival and what i
01:20:31 about mr. Bonifacio survival and what i have not yet revealed is that mr. Bonifacio it was not only elderly not only did he have frailties but mr.
01:20:43 only did he have frailties but mr. Bonifacio is blind yet this blind frail elderly resident trapped in Grantville survived and was the last man out now I
01:20:59 survived and was the last man out now I don't know whether the Black Nazarene also known as El Santo Cristo Mela Grasso or locally known as a I
01:21:11 Grasso or locally known as a I was looking down on this blind frail elderly son of that fishing fishing village known as silent but he survived apparently against all the odds he was
01:21:26 apparently against all the odds he was finally rescued by firefighters from flat 83 on the 11th floor at 8 minutes past 8:00 in the morning and sir here's the thing mr. Bonifacio wanted to
01:21:40 here's the thing mr. Bonifacio wanted to assist you with this inquiry and personally give his account and yet he was not permitted he wants to give you an oral account of his experience during
01:21:54 an oral account of his experience during the fire and efforts that took to rescue him indeed his legal team compiled footage of the fire showing the fire spread around flat
01:22:06 fire showing the fire spread around flat 83 the impact of the ground monitoring in order to prevent the fire spread around his flat and effectively preventing the fire spread into flat 83
01:22:18 preventing the fire spread into flat 83 which we would have wished to present it during mr. Bonifacio's evidence as part of the record to date this is not happening
01:22:28 happening we trust and can only hope that this evidence will form part of the record of evidence relating to that night in due course sir do you know where Pino is
01:22:43 course sir do you know where Pino is this is becoming a panel game let me tell you Penal is a small village in the
01:22:54 tell you Penal is a small village in the south of Trinidad on that twin Caribbean island state known as Trinidad and Tobago it loud lies south of San Fernando and north of the town of
01:23:09 Fernando and north of the town of spiraea it was originally a rice and cocoa producing area Raymond Herbert Bernard was burnt
01:23:20 Bernard was burnt born in penal Raelynn or Moses as he was known to close friends and family was one of seven children born to Rose Bernhard her third child born on the
01:23:34 Bernhard her third child born on the 22nd of May 1954 he had four sisters two brothers and he was a barber of three and an uncle to many and admired by many
01:23:46 and an uncle to many and admired by many Raymond who arrived in the UK in 1969 one of the later Windrush generation attended Isaac Newton boys school in Lapid Grove went on to do his
01:23:58 Lapid Grove went on to do his apprenticeship and become an electrical engineer when he was 16 and worked at the House of Lords Raymond
01:24:09 the House of Lords Raymond reggae and soul and in the early part of the seventies he was part of the Gemini sound sister sir a sound system is a system that
01:24:20 a sound system is a system that comprises of a group of young DJ's with their portable decks powerful speakers and amplifiers who travel back and forth to play records that can be transported
01:24:32 to play records that can be transported from venue to venue Rehman was in a long-term relationship with his partner and companion Karen and they shared a dog named Marley apparently a King
01:24:44 dog named Marley apparently a King Charles Spaniel both Raymond and Karen loved Marley as if he were their only child
01:24:54 child Raymond suffered with ill health to severe arthritis thus making his escape from the 21st floor of Grenville impossible without assistance and a
01:25:06 impossible without assistance and a properly functioning lift sir neither Raymond all Marley made it out of grenfell mr. Bonifacio and mr. Bernard
01:25:20 grenfell mr. Bonifacio and mr. Bernard were good friends mr. Bonifacio Raymond and Marley would often go to the bookies together or to the local pub mr.
01:25:33 together or to the local pub mr. Bonifacio who survived misses his friend Moses sir unfortunately Grenville Tower
01:25:44 Moses sir unfortunately Grenville Tower is now synonymous with lost lives lost loves lost opportunities so to the task at hand so many of our clients have spent the last 18 months in temporary
01:25:56 spent the last 18 months in temporary accommodation battling with the authorities that have failed them nonetheless they remained stoic and resolute in their quest for truth justice and accountability sir as you
01:26:08 justice and accountability sir as you retire to contemplate the next stage of these proceedings yes there are many heart-wrenching stories that night for example in the bill and Malik Shakir who lost six-six of their
01:26:22 Malik Shakir who lost six-six of their family members mother sister three nieces Malik's brother who was married to Nabil sister all trapped in the upper floors of that tower it's difficult to
01:26:37 floors of that tower it's difficult to remain unmoved by Nobles sheer desperation and bravery that night he begged he pleaded in desperate attempts to get inside Grenville tower on the
01:26:49 to get inside Grenville tower on the morning of the 14th of June to get past the police cordon to make contact with his family trapped inside that Tower he too was not offered the opportunity
01:27:02 he too was not offered the opportunity to give oral testimony before this inquiry which is a pity because that would have been cathartic he was not
01:27:13 would have been cathartic he was not placed at the heart of this inquiry he really wanted to give all evidence yet his evidence was not called yes sir
01:27:25 his evidence was not called yes sir there are many personal stories of that fateful night all people all raw all heartbreaking it's also important to
01:27:37 heartbreaking it's also important to note this and recognize that those of us who represent the breathed survivors and relatives are not necessarily a homogenous group who engage with the
01:27:49 homogenous group who engage with the proce process in the same way many engage in this process in many different ways sir also at times they seek different outcomes our client mr. Shakir
01:28:03 different outcomes our client mr. Shakir who sits in front of you today his position is and I say this on his behalf that the following factors were responsible for the death of his family
01:28:14 responsible for the death of his family members
01:28:14 members he wishes to state but the government failure to safeguard the residents of the major fires including Locken all with more robust Building Regulations
01:28:25 with more robust Building Regulations he wishes to state decisions made in relation to the installation of the flammable Cardon is responsible he wishes to state decisions made in relation to budget cuts emergency services by services to the
01:28:38 emergency services by services to the police the ambulance he wishes to state decisions made in relation to the refurbishment works the decisions made in relation to rescue an evacuation decision made to stop mr. communications
01:28:51 decision made to stop mr. communications and information about rescue I am merely his voice to you sir let me continue sir
01:29:06 his voice to you sir let me continue sir although this inquiry has admitted the statements from the Metropolitan Police Service in the London Ambulance Service witnesses who attended the breath of towers part of the balloon light
01:29:17 towers part of the balloon light emergency response into evidence many of our clients have questions of these witnesses that can only properly be answered through all evidence of which
01:29:29 answered through all evidence of which we detailed in our written submissions to you on the emergency responders and I trust in the next phase you will take the opportunity to consider those in particular we had urged and continue to
01:29:43 particular we had urged and continue to urge the inquiry to call the Metropolitan Police responders PC Sangha and p-series to give all evidence during the remaining section of phase 1 their unique perspective is that of another
01:29:57 unique perspective is that of another emergency service with perhaps a different culture than the London Fire Brigade their assessment of the incident shortly after arrival in particular
01:30:08 shortly after arrival in particular sanga's assessment of the need for evacuation of the building at 128 was a critical time when more lives could have been saved we're mindful of dr. barbara lanes
01:30:21 we're mindful of dr. barbara lanes assessment that stay put should have been abandoned at 126 and that safe evacuation of those physically able was possible up until 1:40 or later
01:30:33 possible up until 1:40 or later depending on variables such as the floor it is therefore essential to know what discussion p-series had with the incident commander if at all and whether there was a
01:30:45 if at all and whether there was a discussion about evacuation given the Metropolitan Police Services initial assessment likewise sir the evidence of the ellic helicopter pilots is critical
01:30:56 the ellic helicopter pilots is critical to our client's understanding of the response of the emergency responders and how their loved one died the evidence is particularly important to the Shakya family the family of rain
01:31:09 to the Shakya family the family of rain Bernard and the family of Gloria Trevisan it is imperative that the Metropolitan Police control room operators who advise zeyneb Dean to wave
01:31:21 operators who advise zeyneb Dean to wave at helicopters is called to answer questions relating to that advice given our clients are genuinely concerned that other residents who traveled from the floor to the roof word advice do so by
01:31:35 floor to the roof word advice do so by members of the emergency services in order to be rescued by helicopters this concern is cooperated by varied Neha's evidence that miss mrs. F raha be one of
01:31:48 evidence that miss mrs. F raha be one of the iranian ladies on the 18th floor mentioned that she had bet they had been told that helicopters would rescue them from the top farhad also recalled a discussion about them going to the roof
01:32:01 discussion about them going to the roof onto the roof to be rescued by helicopters although I had didn't know the source of that information it was apparent that that information had been received apparently in a phone call mrs.
01:32:15 received apparently in a phone call mrs. Nitta was also unclear whether the advice wait to be rescued by helicopters from the roof had come from by fighters sir our clients own suspicions that the
01:32:29 sir our clients own suspicions that the presence of the helicopters gave residents particularly those on the upper floor a false hope that they would indeed be rescued and that was shared by
01:32:41 indeed be rescued and that was shared by fire head and other firefighters as we've heard from firefighter Allen more these concerns can any properly be allayed from the
01:32:52 can any properly be allayed from the testimony of the Metropolitan Police Control staff who took the calls from residents in the tower and disclosure of the MPS's call handling guidance protocols in addition to our to
01:33:08 protocols in addition to our to providing our clients with the answers to these questions concerning their loved ones who died this evidence is also necessary to identify the advice given by the Metropolitan Police Service call handlers to call is trapped in
01:33:20 call handlers to call is trapped in order to ensure that lessons are learned from the Grenville tower fire societies well used to and trust in awe of advice given over the telephone and looking
01:33:32 given over the telephone and looking forward online in our interconnected world to not properly examine this in the light of the events in the 14th of June fails to take an opportunity that
01:33:45 June fails to take an opportunity that may never come again sir and we ask you to consider that Martin Luther King jr. said this never never be afraid to do
01:33:57 said this never never be afraid to do what's right society's punishments are small compared to the wounds we inflict on our own Souls when we look the other way sir we hope you do not look the
01:34:09 way sir we hope you do not look the other way on the 6th of June in my opening statement I said on behalf of g11 there has in the openings of others
01:34:22 g11 there has in the openings of others been criticisms of the firefighters capabilities and their reactions on the night that is something that will undoubtedly be considered however we
01:34:34 undoubtedly be considered however we must not lose sight of the primary issues I repeat that let's not lose sight of the primary issues refurbishments the works
01:34:50 issues refurbishments the works I also said on a previous occasion that when 72 souls were lost in the most horrendous an awful wave those responsible should hang their heads in
01:35:01 responsible should hang their heads in collective shame haven't heard six months of evidence there is nothing to make me ultra my view about those
01:35:12 make me ultra my view about those sentiments the fact that mass fatalities mass personal both physical and psychological injury and mass homelessness of innocent residential
01:35:25 homelessness of innocent residential dwellers is quite frankly outrageous the fact that it was caused in this way is just shocking those scars are wounds
01:35:38 just shocking those scars are wounds which are just as raw today previously we said that there are many important questions that needed to be asked so some of those questions have been answered but there's still many more
01:35:51 answered but there's still many more questions which will be left the next phase of your inquiry the fact remain is that and this cannot be avoided sir
01:36:02 that and this cannot be avoided sir once a reasonably safe block was turned into a death trap and I echo but do not repeat these submissions made by some of
01:36:15 repeat these submissions made by some of my other colleagues who have come before me sir I previously said though whilst those responsible for the refurbishment may dispute just how unsafe they made
01:36:26 may dispute just how unsafe they made granville tower it is incontrovertible that the tower was intentionally rendered significantly less safe by the
01:36:37 rendered significantly less safe by the introduction of highly flammable material to its structure and exterior we stand by those remarks it is clear
01:36:49 we stand by those remarks it is clear now that this wasn't this fact wasn't communicated to the London Fire Brigade the fire safety of several hundred people deliberately compromised in their own homes and yet public
01:37:02 in their own homes and yet public servants ultimately responsible for protecting them in the event of a fire was simply never told still less consulting sir key questions in
01:37:14 consulting sir key questions in Grenville how on earth did this happen what went so tragically wrong why is it that so many people died we say at this
01:37:30 that so many people died we say at this stage sir you can answer those questions when my corporate colleagues get their feet to address you after the those of
01:37:41 feet to address you after the those of us represent debrief survivors and relatives sit down sir please be aware of this
01:37:50 of this be wary of attempt to distract divert rewrite history all blame others in an attempt to conceal the truth remember
01:38:03 attempt to conceal the truth remember sir that although we have not yet heard all the evidence and we still have yet to hear the evidence of mr. Ahmed who sits before you who was the chair of the
01:38:15 sits before you who was the chair of the leaseholders Association we met he asked Kensington and Chelsea to conduct a full health and safety audit of Grenville Tower he delivered a dossier to
01:38:27 Tower he delivered a dossier to Kensington and Chelsea two weeks before that fire and yet those steps were not taken don't forget he repeatedly told the TM own to provide
01:38:41 he repeatedly told the TM own to provide and carry out a fire drill queried the absence of any fire safety advice for the residents of grenfell this disaster
01:38:53 the residents of grenfell this disaster happened because ordinary people were ignored it is a direct consequence of that failing sir
01:39:04 that failing sir we've now had the pleasure of your company for the best part of nearly seven months and haven't seen the way that this hearing has been conducted how your inquiry team have operated and how
01:39:16 your inquiry team have operated and how the other core participants have conducted themselves what we can agree on as night must surely follow day is you're not going to please everyone
01:39:29 there simply has not been consistency in the demands made of you it is clear from the written submissions of the core participants that you cannot take a
01:39:40 participants that you cannot take a sword of Solomon approach to this tragedy that engulfed this residential block back in June 2017 split it down the middle and dispense justice to
01:39:52 the middle and dispense justice to satisfy all it ain't going to happen in that way in fact the evidence simply does not permit you to do that it simply
01:40:04 does not permit you to do that it simply does not fall in that way so as I got to my feet you probably thought what's that Lizzie Thomas gonna say today what's he gonna complain about now this some on
01:40:17 gonna complain about now this some on behalf of g11 and it is true but during this inquiry there have been certain themes to the requests that I have made
01:40:28 themes to the requests that I have made of my clients but in fairness to me I have to do my best to hold this inquiry to account and I have to do it fearlessly sir you know you appreciate
01:40:40 fearlessly sir you know you appreciate that those Imams have only been made with good intention trying to assist you in your team in this traumatic process for those I represent and I honestly
01:40:52 for those I represent and I honestly hope that the requests were made with respect politely and with the right tone and sense of humor sir from the perspective of the people who have been
01:41:04 perspective of the people who have been ignored for so long at their personal cost that they feel the need to make complaint and yes they have happy with all aspects of this process
01:41:16 happy with all aspects of this process just by way of example the way that some of the questions have been put the lack of the opportunity to put questions through their own Council the having
01:41:27 through their own Council the having sufficient time to take instructions in between the question of witnesses so as we move from phase from this space to phase 1b and phase 2a we submit that it
01:41:39 phase 1b and phase 2a we submit that it is necessary for our clients questions are asked of questions through their own counsel as you and your counsel will well appreciate your team will have to
01:41:50 well appreciate your team will have to take a very neutral role in the next phases of this of this hearing and some may argue we certainly do argue that they're not properly or best place
01:42:01 they're not properly or best place laughs the search and robust questions that our clients need to be ours the venue and its lack of suitability you
01:42:15 venue and its lack of suitability you may not know this sir but one of my clients Cordelia Cordell discern the widow of Anthony dissing tawny discern and other members of the distant family are among the clients who would have
01:42:27 are among the clients who would have wished to return these hearings more frequently but unfortunately they've been unable to travel to central London mrs. Thyssen suffers from panic attacks and has difficulty travelling and public
01:42:41 and has difficulty travelling and public transport in addition sir we have several clients who've been diagnosed with PTSD as a result this um incident which makes travellingtans inquiry extremely difficult particularly
01:42:54 inquiry extremely difficult particularly in Rashomon like many other clients mrs. Thyssen considers the layout of this courtroom ill-suited for their needs so you will remember days when particular
01:43:07 you will remember days when particular witnesses for in support for example Danny cotton when she was given her evidence this room was filled to capacity and with at times dream rates
01:43:18 capacity and with at times dream rates people
01:43:19 people places start times a small request as we move forward so can we please stick to
01:43:32 move forward so can we please stick to the agreed start times I know it's difficult but we had said and we did announce ten o'clock and we did say that we would aim to finish by four o'clock
01:43:45 we would aim to finish by four o'clock we counted them on 23 occasion sir 23 we've started at 9:30 now don't get me wrong we fully understand that there are
01:43:56 wrong we fully understand that there are times because of the pressure are on the evidence we need to get through the evidence we get that we understand that whilst we as lawyers understand that and
01:44:07 whilst we as lawyers understand that and fully appreciate the inquiries case management duties our clients are trying to make the best efforts to fit in with
01:44:18 to make the best efforts to fit in with your time tabling around their daily commitments school runs childcare arrangements hospital appointments and so all we ask is if you can more
01:44:32 so all we ask is if you can more advanced notice of time changes that would be greatly appreciated disclosure or sometimes the lack of it all
01:44:43 or sometimes the lack of it all sometimes the fact that it comes late an example would be of late dispersion would be the helicopter footage which represented the visual image of the fire spread which actually located people on
01:44:56 spread which actually located people on various floors what one example sir there was images of persons in flat one nine three the shakir family home which
01:45:08 nine three the shakir family home which was seen in the footage between 2:00 and 3:00 a.m. sir as a result of that late disclosure of that helicopter footage received on the 21st of September and
01:45:20 received on the 21st of September and the N ApS pilot statements received on the 28th
01:45:25 the 28th Temba our clients were unable to ask critical questions of witnesses from the control room and just to give you three examples the control room operators
01:45:37 examples the control room operators Sharon Darby who gave evidence on the first and second of August Peter duddy who gave evidence on the 13th of September and the control room manager Joe Smith who recommended the
01:45:51 manager Joe Smith who recommended the who recommended the abandonment of staple
01:45:55 staple additionally sir our clients wanted to ask the CR o--'s and the senior fire officers in the control room questions about the advice given and the change of
01:46:06 about the advice given and the change of the state port with the use of images these images would have been relevant to questions on laughs table mister darden
01:46:16 it was a missed opportunity so I'd now come to the issue of diversity or I should say lack of it sir
01:46:29 should say lack of it sir when is the diversity panel I'm going to be in place is now almost some seven months since the Prime Minister's decision on the 10th of May 2018 for the
01:46:40 decision on the 10th of May 2018 for the appointment of a panel to sit with you and we've repeatedly called for the urgent appointment of a diverse panel and expected all those those expectations may have been false that
01:46:52 expectations may have been false that that panel would have been appointed before the autumn to hear the evidence of the brief survivors and relatives and the experts well that didn't happen so we respectfully asks you to urgently
01:47:04 we respectfully asks you to urgently appoint that diverse panel before the end of 2018 or at the very latest start of 2019 we say that for the following reasons we would ask that the remit of
01:47:15 reasons we would ask that the remit of the panel includes the review of the evidence already heard and received into the record and that you sit with the panel for the remaining of the evidence of phase one relating to those who died and who had near-death experiences in
01:47:28 and who had near-death experiences in the discharge of the article 2 function this is a matter of concern and indeed the general public having a
01:47:39 and indeed the general public having a voice in this inquiry there has been struggle at times for our clients to be heard in this inquiry in the great in the face of great adversity and the
01:47:51 the face of great adversity and the challenges of our clients some of whom are grief stricken with the personal loss from their loved ones they continue to suffer mental anguish and post-traumatic stress yet many of them
01:48:07 post-traumatic stress yet many of them struggle to get here as you move on to the next phase can we make another small ask and it's this a sickness protocol
01:48:20 ask and it's this a sickness protocol for absentee witnesses what we mean by that is this so as you move into Phase two one one being faced to dealing with
01:48:31 two one one being faced to dealing with the movements of those who died all had near-death experiences we would ask you to create or adopt a protocol in
01:48:43 to create or adopt a protocol in relation to witnesses not being called on medical grounds but we raise this Muse two examples Peter May and Graeme winch both witnesses who were excused for medical
01:48:54 witnesses who were excused for medical grounds the inquiry excuse mr. winch for medical reasons and we felt that initially that that was done without providing sufficient detail I'm sure
01:49:05 providing sufficient detail I'm sure there was good reason but Sir it's just a question of involving involved in all so we know we are we as our clients are
01:49:16 so we know we are we as our clients are concerned that in the absence of a proper protocol requiring clear medical evidence where witnesses to be excused of medical grounds our clients are it are concerned and
01:49:27 our clients are it are concerned and these are not unfounded concerns that there may be a risk that witnesses may try to rely on illness as a way of avoiding given evidence
01:49:39 avoiding given evidence now what you need to do sir is and lay those concerns and those concerns can be allayed with a with a a protocol that everybody understands so now the good
01:49:53 everybody understands so now the good news so I'm not here to remind you of any of those matters that I've just mentioned you may be wondering why I'm on why I'm on my feet well let's put
01:50:05 on why I'm on my feet well let's put aside those asks I'm not here to complain about process today what I am here to say to you is and you may all be thinking has mr. Thomas suddenly been
01:50:16 thinking has mr. Thomas suddenly been disabled with that dreaded McComas festive twice as good Willie us that commonly known Latin disease that hits people at this time of the year I know
01:50:29 people at this time of the year I know that you and your team have got a lot of work to do and you're probably gonna have a very short break before you start that work because there is much work for you and your team to do at least this
01:50:40 you and your team to do at least this stage of the proceedings no today is a day not to complain but today's today to let you know our thoughts on how you go
01:50:51 let you know our thoughts on how you go forward and that's what I proposed to do now non-compliance of Building Regulations what we say respectfully you need to be careful of and now is the
01:51:04 need to be careful of and now is the fact that there may well be the attempts to divert and distract the reaching of necessary conclusions to the end of phase one namely clear and unambiguous
01:51:16 phase one namely clear and unambiguous evidence given by the experts which has been so vividly backed up by the survivors and firefighters we say sir
01:51:27 survivors and firefighters we say sir that the failure of the gren fault our that this tragedy was caused because the tower failed and that failure was massive and systemic we know that in
01:51:40 massive and systemic we know that in clear and stark terms we know that because in clearance stock terms your experts
01:51:45 experts so the tower failed for the following reasons and so I'm not gonna repeat in any great detail what you've heard already I'm just gonna highlight um some bullet points for you firstly
01:51:58 bullet points for you firstly overarching of all the failures was the the decision to write this building inflammable material the cladding system
01:52:09 inflammable material the cladding system including the repositioning and insulating of the windows it was so dangerous it meant that a multiple compartment fire was it became
01:52:22 compartment fire was it became inevitable you have our written submissions and you have the written submissions of the other CPS as to why that work is so incontrovertible that
01:52:33 that work is so incontrovertible that the works to install the cladding did not comply with building regulations so we say and we say that you're empowered to do this that the cladding system was
01:52:45 to do this that the cladding system was the primary cause of the fire that spread so significantly that it meant that in grenfell stay-put was no longer viable and secondly that the works to
01:52:58 viable and secondly that the works to install the cladding system undoubtedly made the tower less safe than it was before hand so as dr. dr. Lane said this
01:53:12 before hand so as dr. dr. Lane said this tower should not have been occupied at all and worse still it seems that no one grappled with that fact at the time just
01:53:23 grappled with that fact at the time just as they are doing now all the people involved seem to be convincing themselves that it was somebody else's job to put safety before profit we say
01:53:35 job to put safety before profit we say sir don't accept that excuse that defense not me guv someone else so never has it been a truer saying than
01:53:47 so never has it been a truer saying than more people would learn from their mistakes if they weren't so busy denying them the facts in front of our eyes of
01:53:58 them the facts in front of our eyes of stark and obvious and we know that this inquiry will not shirk from them nothing less than the clear finding of non-compliance of the building regulations will do and so we know you
01:54:09 regulations will do and so we know you know that let me move on sir sir the responsible parties have had ample opportunity yet none of them have
01:54:21 ample opportunity yet none of them have sought to advance a positive case as to why the work to install the cladding system was compliant indeed some appear to accept that such a B would be untenable others are content to explain
01:54:34 untenable others are content to explain why others not them are responsible this is why the cries of unfairness by some of the corporate participants are misguided and are not analogous to the
01:54:46 misguided and are not analogous to the ones made by my clients in phase one because in phase one stood we're not looking at blame this is not about blame at this stage but it's about the
01:54:57 at this stage but it's about the experiences my clients have had which is central to the story as to what happened on the night and which is why we say there's a distinction between their
01:55:08 there's a distinction between their right to participate and that right is properly protected so sir we will argue about who was responsible for that state
01:55:19 about who was responsible for that state of affairs and in phase 2 that will come but let's not detract from the knowledge of somebody must be responsible for this terrible state of affairs in violation
01:55:30 terrible state of affairs in violation of the law and that much demands the immediate recognition by this inquiry the time for action is now not in a year or in two years time so sir the reasons
01:55:45 or in two years time so sir the reasons are set out in detail and our written submissions and I urge you to look at the
01:55:51 the submissions of g11 along with g4 and g3 to assist to declare that the refurbishment works dr. Graham Paul town will not comply in can I just touch upon a few other failures of the building and
01:56:03 a few other failures of the building and I hope to do them so very quickly
01:56:08 importantly dr. Lane confirmed that in her opinion that the building should not even have been occupied even if all active and passive fire protection measures in the tower were fully
01:56:19 measures in the tower were fully compliant and in working order in other words the cladding system made the design incompatible with the staple and unlawful even if for example five doors
01:56:31 unlawful even if for example five doors smoke extractor system were compliant the fire lift worked and the WEP risers present in her view it was simply not possible to mitigate the type of fire
01:56:42 possible to mitigate the type of fire that those materials would cause of course unfortunately those other fire safety measures who are not there are
01:56:53 safety measures who are not there are all working on the night and the club and so the cloggin was not the only reason why be why the tower was a death trap the fact sir that the fire doors to
01:57:07 trap the fact sir that the fire doors to the entrances of 120 flats had been replaced in 2011 and did not comply with fire safety standards there's only one
01:57:18 fire safety standards there's only one stairwell this was the only escape route which was smoke-filled as a result the fire the lips failed to perform effectively hindering the transportation
01:57:30 effectively hindering the transportation of firefighters firefighting equipment creating an unnecessary risk the towers dry riser was non-compliant with the stands of the time of construction and long compliant with the
01:57:42 construction and long compliant with the common standards the smoke control system failed or was inadequately designed and there was no sprinkler system reducing the ability to improve
01:57:54 system reducing the ability to improve both escape and fire fighting conditions these matters sir are secondary to the cladding system in the causes of the fire but they each
01:58:06 the causes of the fire but they each contributed in significant ways to make him the job of firefighting very much harder and the ability of the occupants ourself evacuate fatally on the mind so
01:58:19 ourself evacuate fatally on the mind so that brings me to the issue of firefighting these are our two main points this is an issue we have made written submissions on of course event
01:58:30 written submissions on of course event should should have unfolded unfolded differently yes serious serious mistakes remain lessons must be learned critically however it must be understood and
01:58:41 however it must be understood and repeatedly asserted that a compliant building would not have rendered the safety of so many of its occupants reliant on the decisions of the fire
01:58:52 reliant on the decisions of the fire brigade as dr. lane states that is the foundation of an effective safe stay-put policy the point being here that whilst
01:59:06 policy the point being here that whilst criticisms will be made of the fire brigade and the advice they gave to occupants if the building had not been made so dangerous and state port was
01:59:18 made so dangerous and state port was still working there they would not have had to rely on the fire brigade to at all to put the fire at a safe or safe
01:59:29 all to put the fire at a safe or safe for sir putting the fire out in black 16 as dr. Lane confirmed that is the foundation of a state port policy
01:59:40 foundation of a state port policy although dr. Lane does not go so far as to state that the internal firefighting was fundamentally incompatible with simultaneous evacuation in the tower it
01:59:51 simultaneous evacuation in the tower it is clear that the spread of fire and smoke would have posed serious threats to the health and safety of residents and significant obstacles to effective firefighting in any event for example it
02:00:03 firefighting in any event for example it is telling that dr. Lane believes that believes stair doors being kept open during firefighting activity was the most likely cause of the hot
02:00:14 was the most likely cause of the hot zone on the mid floors which are so obstructed escape and rescue so the point here is that the fire service were damned if they did and damned if they
02:00:27 damned if they did and damned if they didn't the civil contingency act so we up set out in our written submissions the failings of category one responders to adopt a coordinated approach and
02:00:39 to adopt a coordinated approach and respond to the rental Tower in the fulfillment of their statutory duties under the civil contingencies act and others have developed the point the Metropolitan Police didn't communicate
02:00:51 Metropolitan Police didn't communicate their assessment of the need to evacuate the building at 26 minutes past 1:00 in the morning and did not communicate its declaration of a major incident the
02:01:02 declaration of a major incident the number the LA s were slow in their coordination of their response and communication with the London Fire Brigade instant commander and the Royal Borough of Kensington and Chelsea were
02:01:13 Borough of Kensington and Chelsea were they really never got off the mark the plans of the building didn't arrive until 7:00 until after 7:30 after repeated pleas by Andy ro and again it's in concert in controvert
02:01:26 again it's in concert in controvert uncontroverted that they wasn't really real coordination of responses served certainly in the first two hours where we pick up the baton still untouched on
02:01:39 we pick up the baton still untouched on this issue are the lessons to be learned to ensure that the provisions of the civil contingency act are complied with by blue light responders to a major incident training it is palpably clear
02:01:54 incident training it is palpably clear sir from the evidence of Thatcher that he had received limited training on the application of Jessup and of course the natural conclusion affected his and the
02:02:07 natural conclusion affected his and the other MPs response though we've not explored the impact to which the inadequate training had only a bit on the provisions of the civil contingency act or jessep we say contribute to the
02:02:20 act or jessep we say contribute to the inadequacy and lack of coordination of the response of the emergency services in phase one it is clearly relevant sir to the response of the emergency services and we would
02:02:32 of the emergency services and we would therefore invite this inquiry to examine that issue in phase two sir when the Prime Minister announced that you as
02:02:46 Prime Minister announced that you as chair of this inquiry on the 29th of June 2017 she expressed a commitment to unearth in the truth and leaving no
02:02:58 unearth in the truth and leaving no stone unturned she bowed but there would be justice for the victims of this terrible tragedy and for their families who have suffered so terribly the
02:03:09 who have suffered so terribly the grandpa'll community though is still come to terms of their painful loss they've engaged in this consultation they've attended community meetings they've made submissions on the scope in
02:03:22 they've made submissions on the scope in terms of this inquiry and they've become many core participants so what does it mean that there will be justice for all the victims
02:03:34 the victims it can mean only one thing and one thing only that you and your team will do the right thing and the question is when
02:03:47 right thing and the question is when when will you do the right thing well I say time is at this stage because as Martin Luther King would say it is
02:04:01 Martin Luther King would say it is always the right time to do the right thing thank you sir thank you very much mr. Thomas I need them again you hear from mr. Mansfield
02:04:12 them again you hear from mr. Mansfield next but again I think it might be convenient to have a short break to reorganize things so I'll rise and we'll start again at five past twelve please thank you
02:13:15 no mr. Mansfield you're going to make a statement on behalf of the g11 group of BS oh yes thank you thank you good morning
02:13:24 morning [Music]
02:13:25 [Music] coming last as I do this is an interesting and reflective moment because I made it clear in writing that
02:13:36 because I made it clear in writing that although we've made written submissions and they will be no doubt or placed on the website at some point if not already you will have read them and I don't
02:13:47 you will have read them and I don't intend to read them out but what I would like to do is to use a moment of reflection about initially the variety
02:14:00 reflection about initially the variety of approaches within the group that we all represent in other words we would
02:14:12 all represent in other words we would want to disabuse anyone of thinking that we're homogenous and that therefore you can expect the same reactions from everybody they lived on different floors
02:14:25 everybody they lived on different floors they came from different backgrounds and just like any community they have different responses and I've no doubt at all that that will remain there are some
02:14:36 all that that will remain there are some very common responses and I'm going to concentrate on some of the common ones because there is really picking up a
02:14:48 because there is really picking up a theme upon which the last statement ended Lesley Thomas talking about time and I want to develop that because that
02:15:02 and I want to develop that because that is something that you will have seen running through the breeds themselves the witnesses just under three weeks ago
02:15:15 the witnesses just under three weeks ago there was a report published 23rd of November this year and I'm aware that people who read it
02:15:26 and I'm aware that people who read it and no one's disputed its accuracy it was in fact commissioned by the Labour Party but that matters not who commissioned it the actual facts that
02:15:39 commissioned it the actual facts that they revealed are startling and stark and there is a lesson within that very report which you may derive some
02:15:52 substance from in relation to how matters proceeded from today that report revealed that out of 837 high-rise
02:16:09 revealed that out of 837 high-rise according to the definition above 30 meters and 10 storeys a hundred and thirty seven of such blocks in London
02:16:23 only 32 roughly 4% had sprinklers now I began in my opening with a very simple
02:16:36 began in my opening with a very simple back to basics provision I'll return to it briefly in a moment but I'm starting with another one sprinklers before
02:16:50 with another one sprinklers before grandpa'll there were only nine so they've increased a bit so put another way 96% of high-rise council owned
02:17:03 way 96% of high-rise council owned blocks in London don't have sprinklers
02:17:11 now in 2007 the guidance has changed a bit
02:17:15 bit somebody somewhere actually woke up to their efficacy and in fact mayor's say no one's disputing their efficacy not that they would put out the fire
02:17:27 that they would put out the fire here in this case that would never be the suggestion but that they make a major contribution and the commissioner
02:17:41 major contribution and the commissioner who has been described on many occasions in different ways I'm not going to add to it other than the fact that she lent her support as a key feature in fire
02:17:56 her support as a key feature in fire suppression and that is the provision of sprinklers now I'm not going to labor just that because it has a much bigger
02:18:07 just that because it has a much bigger context and this is what I suspect you and the families will be saying and it's a context which interestingly the BBC and mr. Menon himself snoring may be
02:18:22 and mr. Menon himself snoring may be that this is the source of of the example he gives the BBC barely a month before that report had a film which we
02:18:37 before that report had a film which we would urge people to watch at some point the fires that foretold Grenville there
02:18:48 the fires that foretold Grenville there were five fires spread over 45 years
02:18:58 and I want to mention them not in great detail they can be researched the first one mr. Menon mentioned was Summerland in 1973 45 years ago it was followed by
02:19:20 in 1973 45 years ago it was followed by Nestle heights in Merseyside got caught in Irving Heroku McConnell was the last one they took back and was very familiar and of course they've been others what
02:19:32 and of course they've been others what is interesting about the film in a sense besides the detail is that anyone who's watched it will recognize there are discernible themes the discernable
02:19:45 discernible themes the discernable themes throughout starting with Summerland are the three themes I'm going to suggest that are perhaps closest there are others closest to the
02:19:57 closest there are others closest to the hearts of possibly everyone who sits in this room who's concerned with what I call the prism of safety that what has to be placed here is not the prism of
02:20:09 to be placed here is not the prism of profit but the prism of safety if we are to move forward now the three themes I suspect by now everyone in the room could guess what the three themes are
02:20:22 the three themes were firstly given the nature of the fire in 1973 where 3,000 holidaymakers were trapped in this
02:20:34 holidaymakers were trapped in this building burning globules of acrylic rained down on them spreading the flames 51 people died it was in fact at that
02:20:47 51 people died it was in fact at that stage the worst disaster since the Blitz which I can't say I remember but certainly
02:20:57 certainly there are distant memories what happened then
02:21:05 so inflammable cladding or if you like envelope was extremely relevant to that fire that's the first one the second one
02:21:18 fire that's the first one the second one won't surprise you either it is the one I've just touched on in 2018 only 4% of buildings sprinklers would have made a
02:21:34 buildings sprinklers would have made a difference and of course the third one stay put so when one looks at these five
02:21:48 stay put so when one looks at these five fires and the themes that repeatedly come up it's not just that there were themes that were identified but that there were investigations there were
02:22:02 there were investigations there were inquiries there were recommendations on all those topics that large buildings should not be clad in inflammable materials it's almost well it is common
02:22:17 materials it's almost well it is common sense oh yes there's expense oh yes there are ways of getting around it and no doubt those who wish to do that will continue another
02:22:28 wish to do that will continue another topic but there it is writ large from the beginning large buildings should not have cladding that is inflammable there
02:22:39 have cladding that is inflammable there will be disputes over what's inflammable but I leave that for the moment and it was recommended that sprinklers be
02:22:50 was recommended that sprinklers be installed in all large buildings and finally that the policy of stay put should be reviewed
02:23:03 so here we are 45 years later waiting in relation to those three things and a
02:23:14 relation to those three things and a large number of others and we say the importance therefore of reflection on what the various people on
02:23:26 reflection on what the various people on the various floors have been lucky enough to get here ins have survived have to say on these topics is important because there is a risk unless that is
02:23:40 because there is a risk unless that is listened to and I think the word was just used it's time now the question is when is now and what is now and I will
02:23:51 when is now and what is now and I will come to that but before I do it's instructive to remind ourselves of the force of those who we all represent in
02:24:05 force of those who we all represent in this inquiry and I've only asked for a couple that we I think it eases your burden and possibly those in the public if this particular section could be put
02:24:18 if this particular section could be put on screen I have as it were had a conversation with the Ralph's and he's aware this is this is the first one and it relates to a gentleman called Nick Burton you have it in your a small part
02:24:36 Burton you have it in your a small part of what he had to say has already been referred to but I do wish to read this and it can be followed because one sees in the context I've just spelt out of 45
02:24:50 in the context I've just spelt out of 45 years of talk and very little or no action it's hardly surprising once you get to Grenville that you have mr. Burton saying the words that he does it
02:25:04 Burton saying the words that he does it begins on page 89 it's day 68 for anybody who's wanting to look it up and it starts with these words I will just
02:25:15 it starts with these words I will just keep it sweet this is an historic event the consciousness of the nation is looking at all of us how this inquiry how the
02:25:30 at all of us how this inquiry how the police investigation is going but this is so important that it has to stop here
02:25:39 we've seen failings and failings I've been failed so many times you know failings and failings and failings with other fires and other lessons not
02:25:51 other fires and other lessons not learned so Bren fell has to stand for something and it's to stop here about
02:26:03 something and it's to stop here about how people are treated and how the loopholes in the system need to be closed you know we as the survivors and
02:26:18 closed you know we as the survivors and everything where we're fighting against a system that is broken and they know it's broken but you know they usually
02:26:30 it's broken but you know they usually put a sticking-plaster over it and move on
02:26:34 on no disrespect with the inquiries but I think that's just a system initially to save the government of the day any embarrassment oh we're gonna have an inquiry to find out the truth and then
02:26:46 inquiry to find out the truth and then time lapses we do get hopefully to the bottom of this and to find out the truth but it's over a long period of time
02:26:57 but it's over a long period of time we've spent time with the Hillsborough family so we spent time with other people Doreen Lawrence I've been going around the country myself going to
02:27:08 around the country myself going to Manchester Plymouth Portsmouth talking to people and they are absolutely scared of living in tower blocks with that cladding still on so the system is not
02:27:20 cladding still on so the system is not working we meet up with I mean the Prime Minister downwards you know all all the housing ministers they talk that but you know this has to be the one
02:27:33 but you know this has to be the one where it stops justice for me is that you know this never happens again
02:27:41 we have a fair system we've got a lot to deal with especially in this environment at the moment but it has to stop here it can't go on and then we'll be talking
02:27:56 can't go on and then we'll be talking about another major incident where there is a fire and a loss of life and then we're talking about did we learn any lessons from Grenville did we learn
02:28:07 lessons from Grenville did we learn anything from Hillsboro did we learn anything from anything it has to mean serious stuff I mean we've all been through a lot we've got
02:28:22 all been through a lot we've got families here now you know that have had lost multiple people and it's been very very challenging so you know the weight of responsibility is yourself you know
02:28:35 of responsibility is yourself you know to make recommendations may I emphasize the word ease put now and put them into place now and just not just wait for a
02:28:48 place now and just not just wait for a report and then the government say yes we've got the report and now we're going to think about another consultation all process to go through things it has to
02:29:00 process to go through things it has to stop here with Grenville and Grenville I believe will mean something you know changes in regulations changes in attitude social housing all these big
02:29:12 attitude social housing all these big things that previous governments have been just youth has wiping away because it's not their concern at the moment and
02:29:23 it's not their concern at the moment and that's why lives are lost so the lessons have to be learned here and now and stopped here I think
02:29:37 stopped here I think and you then acknowledge him and thank him and we noted that you did that
02:29:48 him and we noted that you did that regularly and we also noted that your counsel mr. millet also I think it was rather late on a Friday possibly a
02:29:59 rather late on a Friday possibly a Thursday but late in the day that's not meant to be any kind of criticism but paid a very real tribute at the end of all those we represent he coming here
02:30:10 all those we represent he coming here and giving evidence a tribute to their courage and in a sense that tribute now needs to be translated and we appreciate
02:30:21 needs to be translated and we appreciate all of us how do you translate it how do you translate it now and I do want to
02:30:32 you translate it now and I do want to address that particular point because the history shows we've waited too long we want no more Grenville's that's the theme the repetitive theme which needs
02:30:44 theme the repetitive theme which needs to be writ large and on our house as we move forward and there is a way forward now that will give confidence to the
02:30:58 now that will give confidence to the public and to particularly the families who suffered so much if the process of in fact shifting what has been the
02:31:13 in fact shifting what has been the maneuverings the machination x' i opened i think those will remember June the for the very same day of the fire those who
02:31:24 the very same day of the fire those who were meeting in private the construction industry and government representatives to see how they could dismantle more of the
02:31:34 the Galatians no one should ever forget that happened on the very same day haven't heard much of it since but that what has to be shifted now in order to as it were
02:31:47 to be shifted now in order to as it were displace that force which underlies if you like the austerity cuts point that's been made in order to displace that and
02:31:59 been made in order to displace that and restore the confidence of people who are so scared they won't live in these blocks it's a form of arrogance it's a form of complacency that runs throughout
02:32:10 form of complacency that runs throughout and no doubt will rear its head in Phase two when some of the responsibilities can be more clearly identified than it has already but there is an
02:32:24 has already but there is an institutional lethargy forty five years there's always a reason why you can't do something now that should always be
02:32:36 something now that should always be overridden by necessity necessity to ensure safety of course they'll say for sprinklers oh we don't know we've got
02:32:48 sprinklers oh we don't know we've got enough water well perhaps it hardly bears examining and then it's the cost so we can't do it now but we're doing
02:32:59 so we can't do it now but we're doing what when none looks at and compares the resources that are spent on not that I understand it quantitative easing and a
02:33:11 understand it quantitative easing and a lot of other examples where billions are spent
02:33:14 spent it's where there's a will there's a way and that's where if you were able to you can bring the influence of the position
02:33:26 can bring the influence of the position in which you've been placed as as mr. Burton said the weight is upon your shoulders it's one I'm sure that will be borne with great dignity and with
02:33:37 borne with great dignity and with thoroughness so everyone in a sense depends on that being carried true and in fact that it's displacing something that was described by Bishop
02:33:50 something that was described by Bishop Jones when he did the review our post Hillsborough it hasn't actually been given a title but it has a title and it's a NAPA site title and its really
02:34:02 it's a NAPA site title and its really the task ahead here the title he gave it the patronizing disposition of unaccountable power was how he was
02:34:15 unaccountable power was how he was describing what had been happening before and in a sense and is what we're now facing accountability comes next disposition we've already seen a bit of
02:34:27 disposition we've already seen a bit of and therefore just going back to sprinklers for one second one of the things but there are others I'll come to one of the things that could be
02:34:40 one of the things that could be considered right now it is being considered elsewhere but as always the action has yet to follow retro fitting
02:34:53 action has yet to follow retro fitting of sprinklers on those existing buildings I've already mentioned so we get not ninety six percent without that ninety six percent or more width
02:35:04 ninety six percent or more width sprinklers and really when you look at it it's incredibly modest suggestion and I'm not saying I go all the way with the suggestion the suggestion is he's only
02:35:16 suggestion the suggestion is he's only going to apply to high-rise over 30 meters ten story and if I can just stand back for a moment what we've heard well
02:35:29 back for a moment what we've heard well yesterday sort of completed the picture from the London Fire Brigade the reason why it's modest in this sense is that if one focuses on that one sprinklers are
02:35:43 one focuses on that one sprinklers are not controversial in terms of efficacy and we're dealing with blocks where people above the tenth floor actually can't expect security from fire because
02:35:59 can't expect security from fire because if a brigade haven't got the appliances and perhaps they don't exist go above 30 meters no doubt if they did the ladders themselves would be unstable there maybe
02:36:11 themselves would be unstable there maybe the old exception to that but not as a general provision so if you're living over the temper you're not gonna get a fire fault from the outside which is of course why sprinklers just might be relevant to that and we're now told you
02:36:24 relevant to that and we're now told you can't expect the London Fire Brigade to be fighting fires simultaneously on multi floors because we believe in compartment ation so the same people in
02:36:35 compartment ation so the same people in those upper floors aren't going to get much help as far as firefighting is concerned and please understand this is not intended as a criticism of the
02:36:46 not intended as a criticism of the London Fire Brigade it is a criticism of a system that is dependent on a predication which I want to question about compartment ation
02:36:58 about compartment ation but he does mean that a were you able in the ensuing months and hopefully weeks able to consider a sprinkler retrofitted
02:37:16 able to consider a sprinkler retrofitted outside and inside these buildings in London of course there are many many more and the rest of the United Kingdom's are not wishing to be exclusive in this in the way I approach
02:37:29 exclusive in this in the way I approach it so and if I can bring forward something I was going to leave to the end but it fits in here the reason why
02:37:40 end but it fits in here the reason why that example and it is only about that there are many others hark back to something that happened in the summer when you very kindly allowed me to make
02:37:52 when you very kindly allowed me to make a statement here which was not what was for warned but not exactly the contents and it was a plea to which you responded clean then before we broke for the
02:38:03 clean then before we broke for the summer
02:38:04 summer was interim recommendations should we say and we still do say be split into
02:38:16 say and we still do say be split into those that do not require any more consideration after 45 years ones that are not essentially controversial and
02:38:30 are not essentially controversial and ones that are even are only established view actually when you install them are going to save money but more importantly
02:38:41 going to save money but more importantly contribute to the saving of lives now the worry that the families have and it's perfectly understood that the the burden you carry involves a hinterland
02:38:54 burden you carry involves a hinterland of documentation a hinterland of witnesses a hinterland of issues and nobody here expects that you go away tonight and write up the whole thing
02:39:07 tonight and write up the whole thing it's impossible everybody recognizes the impossibility in a sense of the task of really doing it quickly might seem unseemly so you can't do that route
02:39:21 unseemly so you can't do that route either but there is a middle route here which would achieve confidence in other words you can be if I can put it that
02:39:33 words you can be if I can put it that way the first public inquiry ever to be able to do something unusual and that is to say well we've heard enough already
02:39:44 to say well we've heard enough already on certain issues I can name some of the others obviously sprinklers is one of them to actually make these recommendations now so that action can be taken and I as chair here plus two
02:39:58 be taken and I as chair here plus two others panel by then will monitor what's going on and by the end of the inquiry I think no one doubts that the likely end is certainly not next
02:40:09 is certainly not next but possibly the year after but even that I don't preempt whatever's in store here I'm only trying to preempt the need so eloquently expressed by mr. Burton
02:40:23 so eloquently expressed by mr. Burton that need has to be satisfied now is the word that's been used and of course how you satisfy it is really the important thing so that's one of the three themes
02:40:39 thing so that's one of the three themes sprinklers I want to move a little closer to the substance of those matters you've heard and as you've heard so much from others I'm not repeating what
02:40:50 from others I'm not repeating what they've said other than to as it were Tull from what they've said matters which I think different though the families maybe there are certain areas
02:41:01 families maybe there are certain areas where there will be agreement and I'm going to take it in a sense logically because you're here at this stage looking at the cause of the fire itself
02:41:14 looking at the cause of the fire itself as well as the emergency response may I endorse and I don't repeat everything that mr. Menon said this morning about hiccup ad and the origin electrical
02:41:28 hiccup ad and the origin electrical origin of the fire and everything he said about again the maneuverings of those responsible for the manufacture of
02:41:40 those responsible for the manufacture of the item concerned and he gave the figures I don't repeat those either but they're also illustrative of the kind of background I've already indicated more
02:41:51 background I've already indicated more generally about other issues and of course just to as it were remind you of what been said by one of your experts
02:42:02 what been said by one of your experts the domestic fire is a certainty it's inevitable I daresay everybody in the room at some stage or another has experienced it now I I'm not trying to
02:42:17 experienced it now I I'm not trying to be facetious about this but every time we have a toaster on fire or the frying pan
02:42:24 pan I don't think the local fire brigade would be too happy to be called out to deal with it and that really would be a waste of resources because most again
02:42:36 waste of resources because most again the same expert went on to say hopeful the big fire start with small once and the small ones nearly always are as mr. Menon was describing starting and the expert in a very small way usually and
02:42:49 expert in a very small way usually and almost inevitably accidentally in all these cases and this one is the same so accidental small fires have to be countenanced when you're dealing with
02:43:01 countenanced when you're dealing with safety I've mentioned this issue and I know of being identified with it perhaps too closely but I'm not elaborate on it this fire originally was extinguish abou
02:43:15 this fire originally was extinguish abou it wasn't actually at that stage a fire mr. Khomeini woke up the smoke alarm was going off only in the kitchen not in the
02:43:26 going off only in the kitchen not in the hallway he goes in to the kitchen he sees smoke I think he said 2/3 of the height of the fridge freezer coming from the fridge freezer behind it that's the
02:43:39 the fridge freezer behind it that's the stage at which were there materials available to him it's no criticism of him and those who represent him should
02:43:51 him and those who represent him should not imagine them this is remotely intended as a criticism of him of course it isn't what I'm we're really saying is and it's interesting because you've
02:44:02 and it's interesting because you've heard it from witnesses in this phase before the refurbishment there were fire extinguishers in the premises not on every floor some people seem to remember
02:44:14 every floor some people seem to remember they were only on the ground floor where there happened to be of course at one stage caretaker concierge or whatever so that if there's a worry that the individual member of the public might
02:44:25 individual member of the public might not know how to use a fire extinguisher the caretaker would now I mention all of that because moving from sprinklers that's the next one consideration being
02:44:36 that's the next one consideration being given
02:44:37 given as it is in most public buildings even this one to accessories that can help stop the fire in the first place but of
02:44:48 stop the fire in the first place but of course there's a bigger issue than this so I move from that so that's the seat we say you can make a very clear finding of where it started and merit are very clear as it were finding is to the next
02:45:01 clear as it were finding is to the next stage namely that it basically gets out of this kitchen and ignites the cladding
02:45:13 of this kitchen and ignites the cladding however comprised whatever you call it a system or a number of components are conic in there their own statement have
02:45:25 conic in there their own statement have made it very clear all the components pretty well they're not all responsible for all of them but that matters not they they except that they were all inflammable and that they knew they were
02:45:36 inflammable and that they knew they were so what they say so well so did the people using it know that there so what do we got here a hornet's nest of people who know they're using inflammable potato but we've used it for years
02:45:47 potato but we've used it for years exactly the 45 years we've been waiting for something to happen to the regulations and so on so we say this is
02:46:00 regulations and so on so we say this is another thing so I moved from sprinklers to extinguishing materials now to the basic situation of inflammable materials on the exterior of the building going
02:46:12 on the exterior of the building going back to summer land enough has been said about it all I would ask is that you give consideration now to doing what the
02:46:23 give consideration now to doing what the government has begun to do and I'm not going to elaborate how far it should go at the moment it's restricted there are certain buildings excluded and local
02:46:35 certain buildings excluded and local authorities are being empowered to remove it from buildings that exist so a statement from you so having heard intimate details in phase one is going
02:46:49 intimate details in phase one is going to carry
02:46:50 to carry more weight than the housing minister or anyone else at the moment and would lend force to the suggestion that there has
02:47:03 force to the suggestion that there has to be a ban but we we did we use a different word at this point I am trespassing into the next stage but I only do that because it provides you
02:47:14 only do that because it provides you with an avenue oh then now answering what can I do now without prejudicing everything else and because the evidence
02:47:26 everything else and because the evidence in this particular aspect is so overwhelming the word massive flagrant they've all been used and you've got of course basically a building that wasn't
02:47:38 course basically a building that wasn't fit for habitation there's not much more that you need really other than to say that the reason the basis for the unfitness has been well established and therefore the word we want to use is a
02:47:50 therefore the word we want to use is a moratorium now now it may be a fruitless exercise at this point to make the finer distinctions about a merit moratorium
02:48:03 distinctions about a merit moratorium there is a a body of opinion that thinks at this stage until it's finally tested that it should be restricted in other words nothing less than a one not even
02:48:19 words nothing less than a one not even the top grades s1 do of a - it may well be they'll come to be exactly the same it may well be there be equivalent and
02:48:30 it may well be there be equivalent and have the European approach but until and this is the point in fact I think mr. Walsh in a sense said it yesterday you know should we be approaching everything
02:48:41 know should we be approaching everything on the basis that it's all going to collapse well don't go that far but I think it would improve matters if the approach was taken that we cannot afford I mean economically and personally or
02:48:53 I mean economically and personally or socially we cannot afford another everybody says it so we've got to be seen to be taking the steps which means to everyone that we mean business here and it isn't
02:49:05 that we mean business here and it isn't a talking shop as as so many people have referred to previous inquiries and so on and a moratorium satisfies that because it's not actually saying it's the final
02:49:16 it's not actually saying it's the final decision it's saying just for the moment until we know finally that a to top grade is the same then that can be let into the club as it were but maybe not
02:49:28 into the club as it were but maybe not for the moment but I don't spend a lot of time on that distinction because more importantly is your willingness to go that extra stage and it's important because it affects the removal point
02:49:41 because it affects the removal point that I've already touched on there are a hundred and fifty seven buildings in London that still have cladding and those buildings although the attempts
02:49:54 those buildings although the attempts being made to take you down you would think after this lapse of time there wouldn't be a single building in the United Kingdom publicly or privately owned which would have the material
02:50:05 owned which would have the material similar which are far far less obviously than a1a2
02:50:10 than a1a2 the grades I've mentioned would not be on a building anywhere yet it is so it needs it needs a push it needs a bit of
02:50:22 needs it needs a push it needs a bit of an initiative if you like a bit of elbowing and a nudging which would not be out of place and would actually earn I'm not suggesting you need to earn
02:50:35 I'm not suggesting you need to earn respect but the inquiry needs to reassure the public that it really has got safety out it's hard so that the cladding issue is important it also bears upon something else which would
02:50:48 bears upon something else which would come at the other end would come at the interim recommendations but I incorporate it here because the interesting thing is of course that the
02:51:00 interesting thing is of course that the the cladding and the associated materials were non-compliant everybody said it no one's denied it so how come how come they did that
02:51:12 how come they did that and it leads to what has been floated and I raise it again now we did I did to put it in my opening and I put it here
02:51:24 put it in my opening and I put it here again just as a theme that needs to be popping up so one has to have regard to it and that is the need now for people to work on and I don't suggest you'd be
02:51:37 to work on and I don't suggest you'd be able to come back after Christmas or early in the new year with answers to this one this does require more thought but you would by now have thought there must be quite a lot of frameworks there
02:51:48 must be quite a lot of frameworks there well there is one Dame Judith hagit came up Hackett came up with one she called it a joint competent authority a regulatory authority the problem with
02:52:01 regulatory authority the problem with her suggestion is that it constitutes most of the usual suspects so it's not truly independent but what we are
02:52:12 truly independent but what we are suggesting needs to be established and unless the thinking is going on now we'll have another ten years why it goes away as its put by Nick Byrne for another set of consultations so one
02:52:25 another set of consultations so one needs to get this as it were the brain cells of those who are working in this field as to is the establishment of the authority who runs it their ability to
02:52:38 authority who runs it their ability to investigate and have inspector and Inspectorate because obviously the idea that another building can cut corners because the as it were the corporates
02:52:52 because the as it were the corporates involved in provision and a local authority and more have not as it were themselves considered complying with the
02:53:04 themselves considered complying with the law that has to be overtaken and the public have to be aware and so does industry that we can't have any more red tape meetings deregulation and so on
02:53:16 tape meetings deregulation and so on it's going to be reregulate such that the Inspectorate itself is able to identify what has been called the do
02:53:25 the do holder in these circumstances who is going to be responsible for security against fire in these situations and we
02:53:37 against fire in these situations and we we have to do that because you can't trust unfortunately as it's been put in that heading the unaccountability of
02:53:49 that heading the unaccountability of power so it has to be brought about that and of course the people who are as it were part of that authority themselves have to be clearly independent of the
02:54:01 have to be clearly independent of the industry they need to have a knowledge of it but they should not be part of it that's not to say the industry should not have some representation so one sees straight away there's a raft of areas
02:54:16 straight away there's a raft of areas where you might be able to tread now fearlessly robustly in order to engage not only the public but the government of the day whichever that happens to be
02:54:29 of the day whichever that happens to be by then so I'm moving into that's that's the start of the fire the spread of the fire and the measures that should be
02:54:42 fire and the measures that should be considered and I'm going to obviously link it to the fire service which I'm coming to now and the emergency response to the cause of the fire and plainly
02:54:57 to the cause of the fire and plainly there will be differences and one shouldn't shy away from me of how the fire firemen are approached and so on and really using the word heroes is not
02:55:10 and really using the word heroes is not necessarily the word they would want used the fact is that it wasn't caused by the fire brigade the majority go
02:55:22 by the fire brigade the majority go there with a genuine intent desperate intent to help the majority there are obviously exceptions as there is in any institution that doesn't absolve us
02:55:36 institution that doesn't absolve us from looking at and for them to looking at how matters might be improved for the future it might not have cracked this
02:55:49 future it might not have cracked this one but it's again getting back to things that were already in place that we're not talking about anything particularly revolutionary or hasn't
02:56:02 particularly revolutionary or hasn't been thought of before knee-jerk reaction know if one looks at I take one at the sheet you have it in the various thing I'll go to a straight to be put on
02:56:13 thing I'll go to a straight to be put on the screen and that is appendix one relating to the act in 2005 and Rescue Services Act can that just be slightly
02:56:25 Services Act can that just be slightly enlarged I don't know perhaps it's just me so because I do want just before lunch ah right I thought it'd be right I know it's been mentioned many many times
02:56:36 know it's been mentioned many many times and it's also mentioned in our written submissions but also the we've done a
02:56:47 submissions but also the we've done a series of tables and we'll go through them all table one of the seven tables that we provided you is actually sets out in detail if you like fire safety
02:57:00 out in detail if you like fire safety policy and all the documents you've heard about it's all there in the one in the one document and what is important here is not so much what else could the
02:57:14 here is not so much what else could the fire brigade have done on the night and impossible fire out of control we know that we realized that they were faced with an inferno whether it should have
02:57:26 with an inferno whether it should have been anticipated I leave for the moment I really want to go back a step and that's what this document really does appendix 172 D again not expecting as
02:57:43 appendix 172 D again not expecting as perhaps mr. Menon thought every fire officer who goes there can do everything no that's not the point the point is creating a different approach
02:57:55 point is creating a different approach to safety a different culture to safety so that fire officers do not have to face their difficulties they do once you obviously overcome a cladding the
02:58:07 obviously overcome a cladding the sprinklers the doors or windows and all the other features active and passive some of which I'll come to perhaps after lunch but this document needs to be read
02:58:18 lunch but this document needs to be read and read again because it's very clear and I paused it on this because there
02:58:31 and I paused it on this because there have been various indications of how this is being followed up but the question I pose is why is it taken Grenville before somebody noticed that
02:58:42 Grenville before somebody noticed that this material required here set out in these many points haven't been accumulated wasn't being put on to mobile data terminals how often did we
02:58:57 mobile data terminals how often did we hear oh yeah we had one button work we turned it on but we couldn't get any information it's not just and that's been conceded very fairly by mr. Worf just yesterday or it's in his written
02:59:09 just yesterday or it's in his written arguments it this the collation recording of information it is vital and of course they can't do every building we know that it ought to be able to but
02:59:23 we know that it ought to be able to but of course it's all got privatized again so it's farmed out to somebody else and actually the job doesn't get done but the job was specified here and if you just go through some of them you be it
02:59:35 just go through some of them you be it begins to ring so many bells you get all my goodness starting right at the top means of access and egress from the site well that's a major problem in the ground full tower had anybody worked
02:59:47 ground full tower had anybody worked that out and anybody marked it up on a plan so they knew where to go and where to park they were having to look round for parking spaces when they got there the
02:59:56 the standards I appreciate more coal than would necessarily be just the old one or two however all of this just because each fire in the five fires that are in
03:00:08 each fire in the five fires that are in that film are all different so what do we do we sound like oh well boy we can't tell until til it happens then we'll do something no sorry you know the elements that cause the trouble in these fires
03:00:21 that cause the trouble in these fires and that they can be unexpected so therefore this is the prism of safety here in this in a sense this one document spells it out the prism of safety which fire officers on the ground
03:00:33 safety which fire officers on the ground and management should be trained to deal with in training as you know also privatized and therefore we say not
03:00:44 privatized and therefore we say not properly accorded its place so and then we come the second item the location and accuracy of information and available on-site well I think we've all
03:00:56 on-site well I think we've all remembered the CCTV and the problems of trying to get information and of course there wasn't anybody on site as there was before the refurbishment the
03:01:07 was before the refurbishment the location and availability of water supplies well that was another issue water pressure and hydrants and so on and in fact it's already been referred to that there this wasn't compliant
03:01:19 to that there this wasn't compliant either that's the dry rises but you've got a series of points all dealing with rising main inlets outlets drain valves isolation valves hydrant locations size
03:01:30 isolation valves hydrant locations size of main parking for pumping appliances within eighteen meters of the rising main what is the point of all this is it
03:01:41 main what is the point of all this is it for somebody's amusement is it supposed to mean that the farm and nip round there for a cup of tea and then come back and somebody feels in one of these they say oh we've done the job for the day that's I'm afraid and that is a
03:01:52 day that's I'm afraid and that is a criticism
03:01:53 criticism I'm afraid this was treated almost as an unfortunate irritant and that occasionally some of it was written up but most of it wasn't and it certainly
03:02:04 but most of it wasn't and it certainly never got distributed in the way that was originally intended onto the mobile data to Terminal so each fire contender going to the scene from Camden Kent or wherever compressor
03:02:17 Camden Kent or wherever compressor button and find out but of course he doesn't work it's another reason why when I come to stay put you cannot depend I'm afraid on the human situation
03:02:29 depend I'm afraid on the human situation and the technology doesn't always work that is why you do have to make the effort to allocate and assemble all this information that is suggested the
03:02:42 information that is suggested the location of the control room the fire control room it provided fire fighting shafts and protected Lobby areas location and function of fire fighting
03:02:53 location and function of fire fighting lifts very important in this case again I'm not suggesting had they done it necessarily more people would have been saved but you don't know unless in fact somebody down a proper review of this
03:03:06 somebody down a proper review of this building because the point also is not just so the fire brigade who obviously have the safety of their firemen very much at the forefront of their minds as well as the public this is also to
03:03:18 well as the public this is also to ensure that the people who own the building or run the building the management are told by the fire brigade or whoever they've unfortunately delegated the task to they come back
03:03:30 delegated the task to they come back after a visit and they say to the owners all the management look here we've been there we can't get a fire engine anywhere near and it hydrants more than 18 meters away the water pressures low the lifts are not working anyway you
03:03:42 the lifts are not working anyway you know where's the drop cane all the rest of it in other words they've got a picture here they have to contribute they have to contribute to the collective responsibility they have
03:03:53 collective responsibility they have along with many others to ensure the safety of the people who are living in in the actual building itself and then interestingly the next item the likelihood and impact of any fire spread
03:04:06 likelihood and impact of any fire spread beyond the compartment of origin and the potential for multiple rescues well that wasn't put there out Phantasy somebody realized that there's
03:04:17 Phantasy somebody realized that there's a possibility that there will be fire spread and that it breaches compartment ation and therefore there's a potential
03:04:29 ation and therefore there's a potential for multiple rescues and possible possibly obviously although it's not written there multiple firefighting so this it's not all entirely unexpected of
03:04:40 this it's not all entirely unexpected of course nobody thought you'd never get a whole building as it were not satisfying everything of course that's nice so what do we do we back off there wolf don't touch it no sorry you do have to pay
03:04:52 touch it no sorry you do have to pay attention to buildings where information of this kind would have made a difference to the approach perhaps not
03:05:03 difference to the approach perhaps not the result on this occasion but maybe the result wouldn't have been in the way it was if somebody had alerted the authorities to the way in which this building didn't satisfy and should not
03:05:15 building didn't satisfy and should not have been signed off next occupancy and use profile by the time of day and day of week occupancy is important in this case because there's another table I
03:05:27 case because there's another table I don't read it out we've put a table I think it's five yes table five we've set out there
03:05:34 out there Anthony distance names on the first page but his name's being mentioned quite a lot in this case but there are others here a large number of people who have a
03:05:46 here a large number of people who have a disability of a kind or they're elderly or they have young children or they're pregnant
03:05:54 pregnant or whatever now one doesn't expect a register to be kept up to date week by week or that you will necessarily know who happens to be visiting that night but to have a picture of people who've
03:06:06 but to have a picture of people who've been there for many years and who cannot easily move mr. dissing being one of them it's absolutely vital a profile and next floor layouts and any
03:06:20 a profile and next floor layouts and any building construction features which may promote rapid or abnormal fire spread such as
03:06:28 such as sandwich panels so what it doesn't say aluminium PE so we didn't think sorry again
03:06:36 again I hope one's not being too / Nikita here ones just saying somebody for once managed to get into an act of Parliament the criteria which would help all of us
03:06:47 the criteria which would help all of us if somebody had managed to do it it's all there and one has to go back to it every time and say this cannot happen
03:06:58 every time and say this cannot happen again that this gets ignored that's something else you could say now that where there are policies or regulations even now before we get around to
03:07:10 even now before we get around to tightening them up phase two or whatever or the more detailed recommendations for goodness sake let's have better attention and to some extent the problem
03:07:22 attention and to some extent the problem here is that the fire brigade response is well we've got projects and reviews in hand well we're very happy to hear about that but it actually needs to be a
03:07:33 about that but it actually needs to be a recognition not that nothing needs to be changed and i'm not suggesting mr. walsh was saying that someone else was but that the project and the reviews in hand
03:07:45 that the project and the reviews in hand with special units so you don't need all that what you need is a watch monitor and a station manager actually to look at this and say oh my goodness no we got
03:07:56 at this and say oh my goodness no we got a job here i'm gonna start tomorrow and you actually depute the fireman on the spot in that station you say well next week you go and do Greenville town or you go and do the first half of the lease it's not difficult for anyone it's
03:08:09 lease it's not difficult for anyone it's not as it were so technical that it can't be done it can be done so floor layouts and construction features plans to show flat oh the fight they had that night try and get the
03:08:21 they had that night try and get the plans which should be on site and there should be a plate and all the rest of it available then we go to plans to show flat and maisonette numbers by floor well there's another problem this all
03:08:34 well there's another problem this all must have been seen by somebody from the local fire station either on their behalf
03:08:41 behalf all from the station itself so that they were away and running into problems in we don't even know the numbers of the they've all been renumber and then we get security measures grills multi
03:08:54 get security measures grills multi locked doors well as you know there was a certainly unlocked well there were problems about getting into the tower access that that should have been sorted or worked out in advance and secondly on the top floor there was that locked gate
03:09:06 the top floor there was that locked gate onto the roof and again they these are details that need to be known in case somebody says oh they've gone on the roof and you can't get the door open so again details of importance we move
03:09:18 so again details of importance we move plans for automatic fire alarm fire suppression systems and means of locating the heads I pause there I'm suggesting sprinklers now in existing
03:09:29 suggesting sprinklers now in existing buildings and if you want to limit it to above ten storeys alright just for the moment just to get it off the ground but of course as they rightly point out here
03:09:40 of course as they rightly point out here an automatic system that allows for the sprinklers to be activated and it is said in those who come after me that
03:09:55 said in those who come after me that there was a smoke alarm but it was silent and activated in fact events which we're coming to what we are suggesting and obviously it can be developed more and if you need to hear
03:10:07 developed more and if you need to hear more that might be one that arrests in the wings for the moment you need an integrated system that alerts the sprinklers the vents and all the rest of it once there is smoke detected and
03:10:21 it once there is smoke detected and which is sounded because you've heard evidence that people actually didn't move because they didn't hear an alarm going off in some cases that's a general one so just coming to the next one
03:10:34 one so just coming to the next one it's five past I think it's rather yeah I'm also aware from various hands going up and down that it's getting rather hot in here well it did but I'm a
03:10:46 rather hot in here well it did but I'm a quite contentious it a bit beyond the usual time it would allow you to finish you know it won't I'm afraid I've got a little bit a little bit I'm doing rather well because
03:10:57 little bit I'm doing rather well because in fact I supposed to be two to three well but you've got remember that your G 11 slot started nearly an hour early yes well I'm very grateful so I think
03:11:09 well I'm very grateful so I think perhaps you should aim perhaps we should aim at allowing mr. beer to stand up at half-past two or oh yes opposed to in court I'll finish by then no as far as you're currently on a point would you can you finish this
03:11:22 point would you can you finish this point reasonably quickly in which case well I can I can hug you yes I was about to deal with I can do ventilation can do ventilation quickly that the points that we want to make
03:11:34 that the points that we want to make here is and it is a major point really concerned with this particular fire and a lot of others including going back to summer land that is toxic smoke or smoke
03:11:46 summer land that is toxic smoke or smoke or thick black smoke this is a real problem because for the individuals living there besides being subjected to it it makes it very difficult for them to make a decision about whether go downstairs or not go down the stairs so
03:11:58 downstairs or not go down the stairs so it's absolutely vital where you have a building that can't pitch fires can't be fought on the outside or the inside above the temple to have a ventilation system that doesn't blow the smoke into
03:12:10 system that doesn't blow the smoke into the building but sucks it out and that's obviously not what was happening it wasn't working the farthest we can go at the moment is according to Barbara Lane anyway is that the design was
03:12:22 anyway is that the design was non-compliant well there are some questions to be further asked on that but you can make a finding at least at that it's a non compliant design for a ventilation system for those living
03:12:34 ventilation system for those living above the as I say V the tenth floor this is not a happy situation so I I won't say more about ventilation at than that because that's a summary of
03:12:46 than that because that's a summary of the situation and we say there should have been an effective ventilation system and if you look at I think it's PSB I can give you the precise reference after lunch it's quite clear it's
03:12:58 after lunch it's quite clear it's conceded this ventilation system had faults in the weeks before and I'll give you the references that I passed - is that a convenient point yes it is right
03:13:09 that a convenient point yes it is right well we'll break there and resume at five past two please thank you very much