London Fire Brigade's closing statement for Phase 1, acknowledging failures while defending firefighters' actions and explaining building regulation limitations.
00:14:18 good morning everyone welcome to today's hearing we've reached the stage at which we're going to hear closing statements from those of the core participants who wish to make them that is oral
00:14:29 wish to make them that is oral statements I've received many written statements some from those who are going to speak and some from those who don't wish to speak so I think we begin by
00:14:40 wish to speak so I think we begin by inviting mr. Walsh is it from the London Fire Brigade to make their closing statement yes with good morning sir sir
00:14:59 statement yes with good morning sir sir it seems a very long time since we attended the commemorative hearings in May to honor those who died as a result
00:15:12 May to honor those who died as a result of the Granville Tower fire but the accounts which were given by those who spoke with such dignity at those hearings remain fresh in the memory and
00:15:24 hearings remain fresh in the memory and are a constant reminder of the reasons why we are still here in December since then the catastrophic events of the night of the 14th of June 2017 have
00:15:39 the night of the 14th of June 2017 have rightly being the subject of intense scrutiny during phase one of the inquiry the London Fire Brigade has always recognized the pressing need for the
00:15:51 recognized the pressing need for the clearest understanding of what happened on the night to be provided to the bereaved survivors and residents of Granville Tower and others affected from women than within the local community it
00:16:04 women than within the local community it close us to the causes of the fire and the manner in which firefighting and rescue operations were conducted beyond that in the wider public interest the
00:16:16 that in the wider public interest the brigade repeats the assertions which it made in its opening statement meaning meaningful less must be learned by many including the
00:16:28 must be learned by many including the brigade and fundamental changes made wherever possible to ensure that a disaster of this kind never happens again
00:16:38 again no one again should be subject to the unimaginable suffering of the bereaved families and friends of those who tragically died in the fire those who
00:16:49 tragically died in the fire those who survived and many of those nearby residents who witnessed the events of the night as they unfolded it is beyond question sir that on the night of the
00:17:02 question sir that on the night of the fire the brigade was faced with the biggest challenge of any fire service in the UK in living memory its policies procedures and training were strained to
00:17:17 procedures and training were strained to their limits and in some respects well beyond that is accepted but that was because in large degree of the sheer
00:17:28 because in large degree of the sheer scale of the incident in multiple respects it is a stark fact that one of the largest fire services in the world was severely challenged in some elements
00:17:40 was severely challenged in some elements overwhelmed in the performance of its functions this was not by reason of an insufficiency or inadequacy of the greatest number of resources ever deployed to a fire in residential
00:17:53 deployed to a fire in residential premises but by a savage fire that rapidly progressed through a building which on the evidence of the inquiries experts was fundamentally non-compliant
00:18:04 experts was fundamentally non-compliant with fire safety requirements in multiple respects this was a unique fire not just because of its unprecedented scale and rapidity but also because of
00:18:17 scale and rapidity but also because of the way it behaved the initial fire of a kind which long-term residents described as being similar to a number of fires which have been attended by the fire
00:18:28 which have been attended by the fire service in the past without difficulty resulted in a major incident involving residential premises on a scale never before experienced in the United Kingdom now there are lessons
00:18:43 the United Kingdom now there are lessons which obviously must be learned with hindsight some have already emerged during the phase wand hearings to which I will come in due course as far as they
00:18:54 I will come in due course as far as they concern the brigade itself and the measures which the Prague Brigade has adopted and the concessions which it makes some of those are detailed much
00:19:05 makes some of those are detailed much later on in the written statement which I'm not going to read out that I will touch upon them in due course but so there is a significant difference between an assessment of lessons which
00:19:16 between an assessment of lessons which can and must be learned in hindsight and a consideration of what incident commanders firefighters and control staff did in the moment to use doctor
00:19:30 staff did in the moment to use doctor lanes phrase they went beyond what might have been expected of them in the ordinary course of their duties and many we know risked their lives
00:19:42 we know risked their lives time and again in doing so firefighters were pushed well beyond their physiological limits in trying to affect rescues and in firefighting at the same time they were required to make very
00:19:54 time they were required to make very difficult decisions in the moment which had significant implications so in addition to assisting you and the
00:20:08 addition to assisting you and the inquiry to fulfill your terms of reference and again with the benefit of hindsight the brigade has invested considerable time and effort in understanding and assessing the events
00:20:19 understanding and assessing the events of the night for the purpose of identifying lessons which must be learned the London Fire Commissioner also ensure that a number of urgent actions we take that were undertaken
00:20:30 actions we take that were undertaken following the fire certain changes of policy have been made already and many are under detailed consideration
00:20:43 mr. chairman the evidence given so clearly by the bereaved survivors and the residents both in writing and from
00:20:55 the residents both in writing and from the witness box has been of enormous importance to the inquiry but also to the brigade in establishing it establishes and helps to establish the
00:21:07 establishes and helps to establish the clearest possible picture of what happened on the night but it went far beyond that it described the human suffering this is a human tragedy on a colossal scale they described the human
00:21:20 colossal scale they described the human suffering of those who were affected by the fire in the most poignant terms it is a testament to their courage in facing and recounting the horrors of the
00:21:31 facing and recounting the horrors of the night for the purpose of assisting the inquiry and in honoring those who tragically perished the firefighters and control staff who gave evidence to the
00:21:45 control staff who gave evidence to the inquiry also found the experience extremely challenging and in any cases particularly heroin those who gave evidence did so from a sense of duty
00:21:57 evidence did so from a sense of duty which is perhaps an old-fashioned phrase but it has a modern current meaning when considered in the context of what they did on the night it was applicable in
00:22:10 did on the night it was applicable in equal measure to their conduct during the fire and in coming to give evidence before the inquiry into a recount and relive their experiences under public
00:22:22 relive their experiences under public scrutiny it was challenging for all of them so immediately following the fire brigade under the instruction again of the London Fire Commissioner deployed
00:22:33 the London Fire Commissioner deployed substantial resources to provide assistance in many forms - both operation north Lee the Metropolitan Police and the inquiry the brigade continues to carry out the complex task
00:22:45 continues to carry out the complex task of analyzing the huge body of evidence which has been gathered in an F to piece together the clearest possible picture of the events of the night that
00:22:56 picture of the events of the night that work has included the compilation as soon as you know of operational response reports for each of the first seven hours of the fire which provide a
00:23:10 hours of the fire which provide a minutely detailed narrative second-by-second where possible of the actions of firefighters drawing together key information from witnesses which are
00:23:22 key information from witnesses which are cross-referenced with breathing out breathing a pelagic apparatus telemetry CCTV and other media a similar exercise has been conducted in the preparation of
00:23:33 has been conducted in the preparation of a single control report which details the actions of officers situated in the brigade control room on the night and that has been and it continues to be
00:23:44 that has been and it continues to be because it is an ongoing process which many resources are devoted to an enormous undertaking and so therefore the brigade hopes that it has provided
00:23:56 the brigade hopes that it has provided real and meaningful assistance to the inquiry both through the preparation of these reports and by facilitating the complex process of taking written statements by the Metropolitan Police
00:24:08 statements by the Metropolitan Police from many hundreds of firefighters who attended on the night and ensuring the attendance of this inquiry of over 90 fire brigade staff who gave oral
00:24:19 fire brigade staff who gave oral evidence it is Sir no exaggeration to say that this inquiry in phase one alone has conducted one of the most extensive
00:24:32 has conducted one of the most extensive and forensic examinations of the events of a major fire which has ever been undertaken but those events did not occur in a vacuum and the inquiry has
00:24:47 occur in a vacuum and the inquiry has inevitably considered matters which touch upon Phase two and which will regular rigorously be scrutinized in that next phase as dr. Lane pointed out
00:24:58 that next phase as dr. Lane pointed out in her initial reports in which she was at pains to emphasize that incident commanders would not have known many of the facts which
00:25:10 not have known many of the facts which have since emerged and that there is an important distinction to be drawn us be drawn between an analysis of the actions of firefighters in the moment in the
00:25:23 of firefighters in the moment in the dynamic and rapidly changing events they faced by contrast with that which may be conducted over several months afterwards in the cold light of day with the
00:25:34 in the cold light of day with the benefit of considerable quantities of material and evidence and that is of course what we sir have been engaged in for the last several months by properly of course evidence has been received for
00:25:51 of course evidence has been received for example concerning the design and construction of Granville Tower but there remains much to be understood as the inquiries experts have pointed out
00:26:02 the inquiries experts have pointed out this concerns among other things the manner in which the refurbishment of the building in which was undertaken and the impact which it had on the active and
00:26:14 impact which it had on the active and passive fire safety measures now therefore if one is looking at the impact on the active and passive fire safety measures and the way in which the
00:26:25 safety measures and the way in which the building behaved that is directly relevant to the actions of firefighters on the day on the night in relation to them so there is much yet to be learned
00:26:37 them so there is much yet to be learned many firefighters have been asked in detail about their individual understanding and adherence to certain
00:26:49 understanding and adherence to certain of the brigades policies and procedures but the basis for the development of those policies must also wait until Phase two and so with that in mind I
00:27:01 Phase two and so with that in mind I want now to touch upon briefly the written closing submissions of some of the core participants just touch upon one or two issues which include a number of criticisms of the brigade as an
00:27:13 of criticisms of the brigade as an organization which part of the legitimate function of this inquiry and part of their right to do so and I'll come to those in due course to
00:27:25 and I'll come to those in due course to some extent but also of individuals now I will come to the brigade itself as an organization later but right now I am
00:27:38 organization later but right now I am speaking of the individual firefighters and control staff who came to give evidence first they did so in relation
00:27:50 evidence first they did so in relation to their training and Brigade procedure with absolute candor that is obvious from the accounts that they gave from
00:28:01 from the accounts that they gave from the fact that they did not always agree with each other on certain issues it would be odd if they did given the number who gave evidence and the traumatic and dynamic events they had to
00:28:13 traumatic and dynamic events they had to recount they had difficult choices to make which involves substantial risks to life either way more than one sir you
00:28:24 life either way more than one sir you may recall firefighters using the phrase damned if you do and damned if you don't just effectively to sum up the situations they found themselves in but
00:28:36 situations they found themselves in but they acted in many instances with heroism paying scant regard for their own safety and returning into the
00:28:47 own safety and returning into the building sometimes time and time again on the instructor's of commanders who themselves struggled profoundly as you
00:28:58 themselves struggled profoundly as you heard them say when they gave evidence with the knowledge that they were deploying colleagues into perilous surroundings they did not give up because they are hardwired to save life
00:29:11 because they are hardwired to save life while there is still a chance and of course similar considerations apply to the control-room staff as individuals who worked constantly entire
00:29:23 individuals who worked constantly entire lessly throughout the night they face numerous personal challenges which were highly distressing and in many cases impossible they were open and
00:29:35 many cases impossible they were open and honest in their views about Brazil brigade procedure and in some cases critical as it was open to them to be but Sir the primary point that I want to
00:29:48 but Sir the primary point that I want to make here is that the evidence they gave was in the context of phase one and it's inevitably limited scope to some extent on the night no one knew as individuals
00:30:02 on the night no one knew as individuals why the fire was behaving as it did no one knew or could have known the conditions in stairwells and lobbies throughout the building so as to make considered certain judgments on
00:30:14 considered certain judgments on evacuation procedures even if an evacuation were possible on a simultaneous basis the inquiries experts
00:30:25 simultaneous basis the inquiries experts who have provided such excellent assistance to be enquiring thus far acknowledge that there remain important issues yet to be studied including a
00:30:36 issues yet to be studied including a clearer picture of the rapidly changing smoke conditions which is so vital to understand before it is possible to come to any conclusions about the viability
00:30:47 to any conclusions about the viability of escaped at particular times and it is after several months of studying the evidence that has emerged since the fire that even then they do not all agree on
00:31:00 that even then they do not all agree on everything in those circumstances sir it would in our submission be unfair to pass judgment on individual actions of
00:31:12 pass judgment on individual actions of any of the firefighters or control staff until more of these issues are fully examined at phase two which is always as we understand it being the intention for
00:31:23 we understand it being the intention for the inquiry and it is impossible to make judgments about what they did without fully acknowledging the sheer scale of what was happening and the rapidity with
00:31:34 what was happening and the rapidity with which
00:31:34 which happened the fact is that none of the firefighters who attended the fire all the control officers in Stratford should
00:31:45 the control officers in Stratford should ever as individuals have been placed in the often impossible situations they were by the by reason of the catastrophic failings in that building
00:31:56 catastrophic failings in that building according to the inquiries experts findings thus far and so that is another reason it's perhaps a secondary reason but it is one of no less importance why
00:32:09 but it is one of no less importance why meaningful lessons must be learned so that fire service staff up and down the country both firefighters and those in control rooms are never placed in those situations again so much for the
00:32:24 situations again so much for the individuals but of course in answer to many of these issues which I have raised in relation to the individuals understandably it has been suggested
00:32:35 understandably it has been suggested that the brigade itself as an organization should have had contingency plans in place to address an incident on this unprecedented scale and training
00:32:47 this unprecedented scale and training implemented to deal with it training is obviously a complex topic in any large organization and particularly in
00:32:59 organization and particularly in relation to the emergency services we say again that the purpose of phase 1 evidence was primarily to examine the factual narrative of the night of the
00:33:11 factual narrative of the night of the fire and in doing so inevitably to touch upon phase 2 issues but it will be only then in phase 2 in our submission when the myriad of factors which dictate the
00:33:22 the myriad of factors which dictate the nature of training can adequately be addressed it is closely linked to policy because you can only train to policy in the emergency services the brigades
00:33:33 the emergency services the brigades policies and training are the product of long years of learning and experience they are directed by the multiple risks which fire services face and which
00:33:45 which fire services face and which exists in the building in the built environment which are constantly changing they must take account of competing risks the availability of resources and funding which is the key
00:33:56 resources and funding which is the key issue the need to address the safety of firefighters and many other complex considerations and at phase 2 according to its purpose those issues can be
00:34:08 to its purpose those issues can be properly and very fully explained and it would in our submission be wrong to pass summary judgment on these matters now before those explanations are before the
00:34:19 before those explanations are before the Environment and so it is for that reason actually as we understand it that the inquiries fire and rescue expert mr. McGurk has not been required to prepare a report for phase one and we await that
00:34:32 a report for phase one and we await that report for the purposes of phase 2 and therefore therefore sir insofar as you've been asked to make critical findings at this stage by which I mean
00:34:45 findings at this stage by which I mean findings other than those of pure fact which determine individual or systemic failings it is the brigades firm position that such findings
00:34:56 position that such findings unless arguably they bear upon urgent recommendations you consider should be made can only properly be made when the full context is examined in phase 2
00:35:12 for sir I turn now to the brigades as we did in the in the opening statement of the brigade to the crucial importance of the principles which govern the design construction and maintenance of
00:35:24 construction and maintenance of high-rise residential buildings and the reason why we want just a touch upon some of the key principles again is that
00:35:35 some of the key principles again is that before it is possible to have any appreciation of the actions of brigade staff on the night of the fire it is essential to restate that fire and
00:35:47 it is essential to restate that fire and rescue services policies and procedures for different types of fires in different types of buildings are underpinned by the regulatory requirements for their design and
00:35:59 requirements for their design and construction the inquiries experts have devoted considerable time and space to these principles in their reports and for good reason but for now as I say we
00:36:11 for good reason but for now as I say we want to emphasize and restate some of the most significant principles first a reminder that the stay-put strategy is
00:36:22 reminder that the stay-put strategy is not a brigade or Fire and Rescue Service procedure it is a key principle of building design and construction but it is one of course that fire services must
00:36:34 is one of course that fire services must understand and apply it is on the evidence of dr. Lane I'm quoting here the single safety condition provided for
00:36:45 the single safety condition provided for the design of high-rise residential buildings the statutory guidance she says makes no provision within the building for anything other than the
00:36:57 building for anything other than the stay-put strategy
00:37:03 it follows sir that fire safety is a crucial element of the building design process which dictates the way in which fire surfaces are expected to carry out
00:37:15 fire surfaces are expected to carry out fire and rescue operations it is not just something which is useful to know or wise to be aware of it provides the fundamental basis upon which fire
00:37:26 fundamental basis upon which fire services are rakaat required to carry out their functions and buildings of this kind buildings such as Granville Tower were expressly designed so as to
00:37:38 Tower were expressly designed so as to contain any fire in its compartment of origin for sufficient time to allow the fire service to extinguish it before it has a chance to spread accordingly the
00:37:50 has a chance to spread accordingly the building design is not intended as the experts of toller's to facilitate simultaneous evacuation of residents especially as this at the same time as firefighting there is for example no
00:38:03 firefighting there is for example no common fire alarm provided for that purpose and the sole means of escape is down a single stairwell and unless provided in some way by the building owner no simultaneous evacuation plan
00:38:16 owner no simultaneous evacuation plan which residents are aware of so in simple terms the design of such buildings is subject to the crucial building design principle known as
00:38:27 building design principle known as compartment ation which we have heard so many times during the last few months and it is intended to inhibit rapid fire spread within the building from one area
00:38:38 spread within the building from one area to another that is achieved as we have heard through a variety of passive and active fire safety measures such as fire
00:38:49 active fire safety measures such as fire stopping fire resistant self closing doors and the use of fire resistant materials in the construction and maintenance of the building the
00:39:00 maintenance of the building the principle applies to each flat in the building to the common corridors and to the single central staircase and lobbies which must themselves be sufficiently protected from the effects of fire and
00:39:11 protected from the effects of fire and smoke
00:39:12 smoke and crucially in this case similar similarly similar but differently expressed
00:39:21 expressed principles apply to the external envelope of the building which is expected to be designed and constructed in such a way as to resist the spread of
00:39:32 in such a way as to resist the spread of flame over its surface so the express intention of the regulatory regime is that in the event of fire the occupants
00:39:43 that in the event of fire the occupants of flats within the building are safe to remain in place according to the regulatory principles to stay put unless they are directly affected by
00:39:54 unless they are directly affected by fire smoke or heat and that is obviously an issue which is under close scrutiny in this inquiry that is particularly
00:40:05 in this inquiry that is particularly important though given the fact that simultaneous evacuation of the building is not factored into the statutory requirements which govern the design of buildings of this kind we make no
00:40:18 buildings of this kind we make no apology for repeating that the stay-put strategy is not a creation of fire services in the UK but rather a principal building design which underpins the development of fire safety
00:40:30 underpins the development of fire safety and operational policy for buildings of this kind so it is obvious in those circumstances that strict adherence to the principle of cotton compartment
00:40:42 the principle of cotton compartment ation through a range of active and passive fire protection measures is is critical to the safety of such buildings in their residence in case of fire now I
00:40:54 in their residence in case of fire now I have no doubt that people have spoken to friends and relatives and I know I have at home and think of the stay-put strategy and the brigade is well aware
00:41:07 strategy and the brigade is well aware as am i of the fact that the stay-put strategy which I have described as part of the regulatory building design is something of
00:41:20 a counterintuitive operation when you've said why would you stay in a building is on fire enough to get out but it is important to emphasize particularly for
00:41:31 important to emphasize particularly for those who live in such buildings that this system of building design which is required by the building regulations has
00:41:42 required by the building regulations has it's important to say this has achieved its purpose in the vast majority of cases for decades in accordance with the principles upon which these buildings
00:41:53 principles upon which these buildings were built by contrast with substantial refurbishments which may have occurred in later years and just to put some context on that we said this in our opening statement that it's worth saying
00:42:04 opening statement that it's worth saying again there are for example in London about five thousand residential high-rise buildings that's in London alone and the brigade attend about seven
00:42:17 alone and the brigade attend about seven hundred fires in such building each year and in the last five years to the end of 2017 which obviously does not include the Granville tower fire ninety four
00:42:28 the Granville tower fire ninety four percent who were resolved by the initial attendance of fire crews and I suppose the key point is that only two percent needed the attendance of six fire
00:42:40 needed the attendance of six fire engines or more and it had never been necessary to suspend the stay-put strategy for an entire building in all at that time not for decades and the
00:42:54 at that time not for decades and the suspension of the stay-put strategy on the night of the 14th of June 2017 was the first time that it had occurred insofar as we are aware ever and the
00:43:07 insofar as we are aware ever and the national picture as we understand it is much the same that is not because every building however has always performed perfectly in respective compartment ation because fires such as these those
00:43:21 ation because fires such as these those which have been attended over the years and been addressed very often by the first crews who attended in those kind of fires breaches of compartment compartment Asian
00:43:33 compartment Asian some degreed have not been uncommon and it's a misunderstanding of Fire and Rescue policy to assume that any breach of compartment ation will always result
00:43:45 of compartment ation will always result in the need to effect a full evacuation of an entire high-rise residential building even if it were possible to do so and that is because in practice fire
00:43:57 so and that is because in practice fire services address localized breaches of compound compartment ation through a system of sector ization we we haven't
00:44:08 system of sector ization we we haven't had a great deal of evidence about this or we have heard some in phase one and I'm very conscious of the fact that I shouldn't be giving evidence but I anticipate that in Phase two an analysis
00:44:19 anticipate that in Phase two an analysis of the principle of fire service practice which is sector ization will be made it involves important to understand that not this now establishing it not an
00:44:30 that not this now establishing it not an operational fire sector in a building where the main firefighting and rescue operations are taking place which typically in incorporates the floor
00:44:43 typically in incorporates the floor involving the compartment of origin and one floor above one floor below within that fire sector the flats above an
00:44:54 that fire sector the flats above an adjacent of the compartment of origin can be evacuated if necessary and further evacuation within the fire sector may be considered or implemented depending upon the development of the
00:45:06 depending upon the development of the fire beyond the
00:45:10 compartment of origin now Brigade policy and Brigade policies all over the country provide for sector eyes firefighting and rescue and the
00:45:23 eyes firefighting and rescue and the practicality of partial evacuation in certain circumstances such as those that occurred at shepherds Court about which we have heard much on the 19th of August
00:45:34 we have heard much on the 19th of August 2016 where that policy was engaged the fire sector was extended to account for the fire spread within the building and limited evacuation of flats in the
00:45:46 limited evacuation of flats in the localised sector was affected the fire was extinguished within the sector without spreading to the rest of the building and without a full-scale evacuation and that is chiefly because
00:46:00 evacuation and that is chiefly because the design principles in the building regulations to some extent contemplate an element of compartment ation failure by providing for layers of redundancy in
00:46:14 by providing for layers of redundancy in various active and passive fire measures so if one fails another one is there and then if that fails another one is there and that's why fire services the brigade
00:46:26 and that's why fire services the brigade in London have been able to one have under policy managed buildings of this kind for decades however in the Grenville tower fire it was impossible
00:46:37 Grenville tower fire it was impossible to adopt a sector ization process on the basis of localised fire spread the uniqueness of the fire which was evidenced by the rapid vertical lateral
00:46:49 evidenced by the rapid vertical lateral and downward spread possibly encouraged as we understand it from the inquiries experts by the existence of the architectural crown wholly compromised
00:47:01 architectural crown wholly compromised the stay-put strategy in other words the condition of Granville tower was such that the fire protection measures which should have been in place in layers of redundancy and upon which Fire Services
00:47:13 redundancy and upon which Fire Services and residents rely were substantially absent
00:47:17 absent and the importance of the statutory fire protection measures was emphasized by dr. lane when she gave evidence all the way back in June she said importantly I can quote from a
00:47:31 she said importantly I can quote from a passage of the evidence which she gave into the fire protection measures must be construed and then maintained to ensure that they are fit for purpose in
00:47:42 ensure that they are fit for purpose in the event of fire the stay-put strategy is provided through design construction and ongoing maintenance all building occupants including the fire brigade
00:47:54 occupants including the fire brigade rely on it in the event of fire it is the simple it is the single I come back to what she says about this the single safety condition provided for in the design of high-rise residential
00:48:06 design of high-rise residential buildings in England the statutory guidance makes no provision within the building for anything other than the stay-put strategy there is no means of warning nor a means to communicate the
00:48:21 warning nor a means to communicate the need to with residents for building their need to increase the areas to be evacuated as is currently regulated for for other types of building uses and
00:48:32 for other types of building uses and that's one lesson that we can learn quite early on so forgive me for just trying to touch upon some of the key principles of building design but it was
00:48:44 principles of building design but it was important to do so so as to understand what firefighters and commanders were doing on the night and we know that it is understandably and properly said by
00:48:55 is understandably and properly said by some core participants that the principles upon which buildings like this are designed and the reliance placed on them by fire services is all well and good but when they fail on the
00:49:08 well and good but when they fail on the scale which occurred at Grenville tower what is the planned alternative and that's a legitimate question which has to be answered the answer to many of those questions in
00:49:19 the answer to many of those questions in relation to the night of the fire can be found in the sheer scale and the rapidity of what happened and the fact that it was unprecedented but to
00:49:30 that it was unprecedented but to understand what the alternatives might have been even with hindsight it is important to recognize how the statuary design principles actually impact upon
00:49:43 design principles actually impact upon what our option the fire services may have in the event that a building fails in its safety design to the extent see Matt Graham guitar so I just want to
00:49:55 Matt Graham guitar so I just want to touch upon some of the practical issues that arise for fire services arising out of the design principles that I've touched upon first of all simultaneous
00:50:09 touched upon first of all simultaneous evacuation since the early 1960s the design of active and passive fire protection measures in buildings of this kind since the early 1960s has not
00:50:24 kind since the early 1960s has not complicated combat contemplated a total building evacuation that is not to say of course that a full evacuation of such
00:50:35 of course that a full evacuation of such a building in certain circumstances happened before might not be possible given time and with favorable conditions particularly where residents are aware of an evacuation strategy provided by
00:50:49 of an evacuation strategy provided by the building owner but the challenges faced by the brigade on the night of the fire were significant rendering the possibility of simultaneous and immediate full evacuation virtually
00:51:00 immediate full evacuation virtually impracticable the following factors are important in that first the building as we have said give me for repeating it wasn't designed or constructed to facilitate such evacuations secondly
00:51:14 facilitate such evacuations secondly there there's an absence of any practical mechanism by which to effectively communicate with occupants of the entire building thirdly there is an available single staircase only which
00:51:27 an available single staircase only which is also to be used by firefighters in breathing apparatus and so on but fourthly and this is important that in buildings of this kind if there is
00:51:38 buildings of this kind if there is widespread failure of active and passive fire protection measures the likelihood that rapidly changing conditions in the building as the fire developed might
00:51:49 building as the fire developed might create toxic and potentially lethal conditions through which residents would be required to pass without respiratory protection and that last point the
00:52:02 protection and that last point the fourth is of particular relevance here a year and a half after the fire and following extensive analysis of multiple issues the inquiries experts at least some say that a detailed consideration
00:52:15 some say that a detailed consideration of the spread of smoke within the building is a very complex undertaking which is yet to be done fully the brigade is carrying out in its own extensive analysis of it and is far from
00:52:28 extensive analysis of it and is far from being able to conclude with any certainty yet though that time will come precisely what was happening in terms of the spread of Smith Witnesses both firefighters and residents have given
00:52:40 firefighters and residents have given their own valuable accounts which among other things demonstrate that the pattern of smoke spread was variable from an early stage professor purser who recently gave
00:52:53 professor purser who recently gave evidence conducted his own assessment but said he hadn't yet had an opportunity to consider the firefighter evidence which is obviously a century before coming to any conclusion sir so I
00:53:06 before coming to any conclusion sir so I would intend to turn now I'm going to be about an hour and a quarter around 20 minutes so I'm not going to take my hold - well maybe relief to hit but I intend
00:53:19 - well maybe relief to hit but I intend to turn now I'm not relieved was no no further
00:53:22 further perhaps it's me but I want to turn now to the website before you can I assume that you would rather complete the whole of your say it without a break I think so yes before that I'll certainly
00:53:33 so yes before that I'll certainly conclude before though before that's right that mid-morning break but so I want to turn now then to these statutory requirements and the way in which the impact on firefighting on the night as
00:53:44 impact on firefighting on the night as opposed to general principles internal firefighting the statutory requirements are predicated on the basis that fires and compartments must be fought
00:53:55 and compartments must be fought internally and that that is the principle which supports fire service policy and training for such fires the inquiry is heard that the deployment of external Jets of water into an internal
00:54:09 external Jets of water into an internal compartment through a window cannot be done safely in high-rise residential premises or others actually because of the risk to which firefighters or residents within the compartment would
00:54:21 residents within the compartment would be exposed it can cause boiling steam and all sorts of other difficulties so great care has to be taken in relation to fight ative to putting water straight into a window
00:54:32 to putting water straight into a window in which people are already there in the course of the hearings though it has been suggested that it may have been an option to abandon internal firefighting
00:54:45 option to abandon internal firefighting it's a perfectly legitimate suggestion but it has been made just to abandon internal firefighting altogether in the early stages of the fire so as to allow an external jet to aggressively attack
00:54:57 an external jet to aggressively attack the fire on the cladding above and below the window in flat 16 without risks to firefighters within the component now of course that window of opportunity
00:55:08 course that window of opportunity because of the rapidity with which the fire spread was very short but it is also a fact that several attempts were made to attack the fire externally in
00:55:20 made to attack the fire externally in order to prevent vertical fire spread an external Jeff was applied to the cladding and the vicinity of the window as we've heard flag 16 in the early stages but with care for the reasons
00:55:31 stages but with care for the reasons which I've explained in the knowledge that firefighters will within the compartment hoses word to float deployed externally from within flat 16 at considerable risk to the
00:55:44 flat 16 at considerable risk to the firefighters who lent out of the window to do it and later aerial appliances were used but in all cases these effort efforts were without material effect to
00:55:55 efforts were without material effect to the vertical spread of the fire and it is a cruel irony that one reason for that may have been that the rainscreen cladding did its job insofar as it
00:56:06 cladding did its job insofar as it repulsed water applied from the exterior but assuming that it would have been reasonable at the early stages to anticipate that the fire in the external
00:56:18 anticipate that the fire in the external carving would spread as far and as rapidly as it did it would have been a fundamental and unprecedented departure from high-rise firefighting procedure to
00:56:30 from high-rise firefighting procedure to abandon internal firefighting because it would have allowed the internal fire to develop further breaching compartment ation and potentially impacting on access and egress routes so there have
00:56:45 access and egress routes so there have also been understandable suggestions that the fire might have been fought externally in the initial stages using an aerial ladder but we can provide more
00:56:56 an aerial ladder but we can provide more analysis of this at Phase two but the inquiry is aware that the brigades initial predetermined attendance the PDA to high-rise fires in June 2017 did not
00:57:09 to high-rise fires in June 2017 did not include an aerial ladder but even if an aerial appliance had been on the PDA it is unlikely highly unlikely that he could have positioned and set up in
00:57:22 could have positioned and set up in sufficient time to have been used to undertake firefighting operations that could have stopped the external fire spread because of the short window of opportunity that was that was available
00:57:34 opportunity that was that was available if that was going to happen turning now to the extent to which firefighting on multiple floors is provided for in the in tribulations while we've said that
00:57:46 in tribulations while we've said that the statutory requirements for the design of high-rise residential buildings provide for internal firefighting they do not contemplate that fire services may be required to
00:57:59 that fire services may be required to fight fight fires on multiple floors just not complement contemplated by the regulations at Granville Tower of course firefighting on multiple floors was
00:58:10 firefighting on multiple floors was essential notwithstanding the fact that the building wasn't designed to facilitate it this meant that doorways from numerous lobbies to the stairwell were required to be open for a significant period
00:58:23 to be open for a significant period thereby necessarily to some extent breaching the protection provided for an escape route and of course that would also have been the case in a full simultaneous evacuation of the building
00:58:35 simultaneous evacuation of the building and whether a building is fitted with dry or wet risers whether there should have been dry wet risers in brimful tower in either case the provision
00:58:47 tower in either case the provision provided for is for firefighting jets to be connected to the rising main which is sufficient to deal with a single compartment fire that's how the building
00:58:58 compartment fire that's how the building records of regulations plan for these things the use of further hoses you're talking about two two hoses are on each floor the use of fir those is connected
00:59:10 floor the use of fir those is connected to riser outlets where the wet or dry in to fight fires on other floors at the same time and results in an exponential reduction if I can use that work in
00:59:22 reduction if I can use that work in relation to reduction anywhere in water pressure to a degree which renders the ability to extinguish fires inadequate on multiple floors if they're all being used at the same time that's the way the
00:59:33 used at the same time that's the way the construction and design for the building is accommodated so in short the available water supplied via the rising main and the associated water pressures are insufficient to accommodate multiple
00:59:46 are insufficient to accommodate multiple hoses in the riser outlets on multiple floors so that the possibility of that firefighting may need to be that firefighting mainly to be affected in such circumstances
00:59:57 to be affected in such circumstances just isn't contemplated by the regulatory regime that's another lesson it might well be learned and perhaps
01:00:08 it might well be learned and perhaps perhaps is likely perhaps that's why the ventilation system in the building was designed only to extract smoke from one lobby at a time and was not capable as
01:00:20 lobby at a time and was not capable as we understand it even if it had been working correctly of doing the same job on multiple floors so so those are all factors which together with the many
01:00:32 factors which together with the many others which are addressed in in the brigade state which I went slavish to go through contribute to what was the reggae firmly maintains a unique and singular event but importantly they
01:00:44 singular event but importantly they demonstrate how difficult it is to develop contingencies for firefighting and rescue where there is a widespread failure to adhere to the design
01:00:56 failure to adhere to the design principles in residential high-rise buildings I say it was a singular fire and it was but the brigade is very
01:01:08 and it was but the brigade is very conscious of the fact that the inquiry is heard about other fires and the brigades knowledge of other fires around the world and I just want to deal with that if I may in this case the spire
01:01:23 that if I may in this case the spire safety measures in the building which for more than 40 years had served its occupants well from a fire safety perspective where on the evidence of the inquiries experts so compromised to such
01:01:36 inquiries experts so compromised to such an extent
01:01:41 that the events of the of the night of the fire occurred as they did but they weren't not yet fully understood by mid 2017 now should the brigade should fire
01:02:01 2017 now should the brigade should fire services fixed with the knowledge of fire spread in other buildings around the world have been alerted to something
01:02:12 the world have been alerted to something which might have assisted in developing contingency plans now the references in phase 1 as we know to other fires around the world demonstrated that there were
01:02:25 the world demonstrated that there were fires which broke out in external cladding and which spread usually vertically practically every case vertically as the experts have pointed out and certainly the inquiries experts
01:02:38 out and certainly the inquiries experts have said that the information about those other fires is not as well-documented as they wish in order to make comparisons and draw specific conclusions the brigade agrees with that
01:02:50 conclusions the brigade agrees with that but also points out that they were very different fires in different buildings around the world with very different regulatory design regimes we set out
01:03:02 regulatory design regimes we set out some examples of those in the statement which I won't repeat here but importantly the brigade entirely recognises the fact that the fires in
01:03:13 recognises the fact that the fires in other buildings around the world which involve cladding materials our important factors to consider when assessing the collective knowledge of fire services in the UK about rapid fire spread on the
01:03:26 the UK about rapid fire spread on the exterior of buildings and the lessons which can be learned from them the extent to which the brigade was fixed with this knowledge and the manner in which it was used and disseminated and
01:03:38 which it was used and disseminated and might have assisted in contingency planning will obviously be a significant issue at phase 2 when those were the relevant responsibilities and expertise
01:03:49 relevant responsibilities and expertise about these issues will have an opportunity to provide a detailed explanation before the present the brigade has taken actions many actions and in this case it
01:04:03 actions many actions and in this case it includes a new procedure through the national operational Learning user group it's a process with the Institute of fire engineer
01:04:14 fire engineer engineers to extract learning from internet national events and disseminate the relevant learning coherently on a nationwide basis and that work is in training is ongoing now but on the
01:04:29 training is ongoing now but on the evidence of survey inquiries experts what was unusual about fire her Grenville tower was the extent of the lateral and downward spread the lateral
01:04:41 lateral and downward spread the lateral and downward spread in the external envelope and the extent to which internal compartment ation was compromised that fire behavior was according to the experts the function of
01:04:52 according to the experts the function of a combination of factors including the nature of the materials used in the cladding and their complex arrangement which is a fundamental and important factor the involvement of the
01:05:04 factor the involvement of the architectural crowd and the manner in which the new window sets had been installed and this combined with the range of internal active and passive fire protection measures created what
01:05:16 fire protection measures created what the brigade really maintains was a unique set of circumstances but they're not unique now because they've happened and that's wide lessons are urgently being learned about so given what given
01:05:32 being learned about so given what given those facts and what was happening in that way on the night of the fire I just want now sir to turn upon just touch upon certain issues with which arose and gave firefighters and control staff
01:05:44 gave firefighters and control staff dibbles is on the night the primary cause of the problems faced by them was described by dr. lay as the rainscreen cladding assembly quote together with
01:05:55 cladding assembly quote together with the insulation fitted to the existing external wall and the missing or defective barriers became part of the successful combustor process this created a condition in the
01:06:07 process this created a condition in the event of an internal fire cavity fire or an external fire that connected every flat on a story and every story from
01:06:18 flat on a story and every story from level 3 to the roof which supported the spread of external far back into the building through windows and created a series of external for internal fire events that's how she summarizes it but
01:06:32 events that's how she summarizes it but importantly she went on to say this I do not consider it it's reasonable that in the event of the installation of a combustible rainscreen cladding system on a high-rise residential building the
01:06:46 on a high-rise residential building the fire brigade should be expected to fully mitigate any resulting fire event that's her view this is particularly set in circumstances where the fire brigade have never been informed that a
01:06:59 have never been informed that a combustible rainscreen cladding system had been installed in the first place further there are so many combination of air but of events she says that could
01:07:11 air but of events she says that could fall entirely outside the reach of external firefighting activity this is important when only internal firefighting arrangements are made for
01:07:22 firefighting arrangements are made for high-rise residential buildings by regulation at this time so those were the among the issues that firefighters and commanders faced on the night
01:07:35 and inevitably it was necessary for policies and procedures which had been established by the fire brigade for many long years had to be departed from now
01:07:46 long years had to be departed from now it has been suggested during the course of phase 1 that there must have come a time when it was clear to firefighters that the fire could not be controlled
01:07:57 that the fire could not be controlled and that there should have been a decision to abandon firefighting completely in favor of the rescue effort that's a suggestion that some have made it's an understandable suggestion but in
01:08:11 it's an understandable suggestion but in addressing that suggestion it's first important to point out that firefighting and rescue operations are not mutually exclusive in all cases it is of
01:08:25 exclusive in all cases it is of paramount importance for firefighters to attack and extinguish an exit in an initial fire so that it is not given the opportunity to spread in cases involving
01:08:36 opportunity to spread in cases involving multiple fires in the premises it's equally important to continue firefighting efforts notwithstanding the difficulties created by the building
01:08:47 difficulties created by the building design not only to prevent further fire spread but also to protect escape routes and to allow rescue attempts to be made and as the fire developed through
01:09:01 and as the fire developed through Granville tower it was essential that firefighting operations continued for to abandon them it would further prejudice the possibility of escape from flaws on
01:09:13 the possibility of escape from flaws on which the fires had broken out and from other flaws both above and below by reason of the smoke and heat which the fires generated and it was essential so
01:09:26 fires generated and it was essential so long as there might be savable life within the building that firefighting operations continued so as to check the continued development of the fire
01:09:37 continued development of the fire internally and to maintain the structural integrity of the and as one example we can all remember that that is precisely what firefighters did to protect mr. Foote Bonifacio in
01:09:51 did to protect mr. Foote Bonifacio in his flat he was partially sighted as he as he explained he couldn't get out but that's how the firefighters behaved in protecting his position until he was
01:10:03 protecting his position until he was rescued by firefighters as late as 8 o'clock in the morning just coming to the rescue operation the inquiry now has
01:10:16 the rescue operation the inquiry now has taken both oral and written evidence from firefighters telling of multiple dilemmas they faced when they were committed to the interior of the building as I think is very well known
01:10:29 building as I think is very well known by now more firefighters in breathing apparatus were deployed into the building than in any other single incident in the collective memory of the brigade more than 700 fire service
01:10:42 brigade more than 700 fire service personnel were engaged in the emergency response firefighters with breathing apparatus carried out many rescues of residents from within flats and assisted
01:10:55 residents from within flats and assisted many other residents who they encountered elsewhere in the building to make their own escape down the stairwell and in many cases they remove their own masks from their own places to give
01:11:07 masks from their own places to give clean airs of residents to protect them from the toxic conditions those have all been described in vivid terms I know but
01:11:18 been described in vivid terms I know but one of the most important purposes of their evidence was to describe the conditions in the building and that's why we say again that a full analysis of
01:11:29 why we say again that a full analysis of the descriptions which they made must be undertaken
01:11:37 one of the issues which is arisen is the extent to which firefighters always made it to the flats that they were that they were deployed to get to now the instinct
01:11:51 were deployed to get to now the instinct of firefighters who encountered residents in the common areas and within individual flats was to affect rescues wherever possible often at significant
01:12:05 wherever possible often at significant risk as I have said to their own safety but that in itself presented a significant problem for the bridgehead commanders because when firefighters are
01:12:19 commanders because when firefighters are committed to a particular flat and they're heading to that flat and they encounter residents in distress on the stairway as they come down they could not pass them by and say they had to
01:12:32 direct them down the stairs or in some cases take them down the stairs themselves and that presented bridgehead commanders when committing crews to specific flats with significant difficulties
01:12:48 it in the moment in the dynamic and changing situations that occurred on that night those were very very difficult circumstances to address with
01:12:59 difficult circumstances to address with any kind of certainty accounts were given by firefighters during the hearings of difficult choices they were required to make involving the viability of immediate rescue the number and the
01:13:13 of immediate rescue the number and the vulnerability of the residents they encountered and whether to advise residents to remain in relatively clean air or to encourage them to venture into a hazardous and toxic environment and
01:13:24 a hazardous and toxic environment and attempt scape down the stairs and I want to pause now here briefly just to recognize the reality of the firefighters situations but they're
01:13:38 firefighters situations but they're wearing heavy breathing apparatus there they've got masks over their faces sometimes they're on the second or third time into the building they are
01:13:49 time into the building they are sometimes literally feeling their way up and down the stairs or in the lobbies because the smoke is so thick that there is zero visibility and many of the residents of course describe the same
01:14:01 residents of course describe the same conditions they are having to balance competing demands and they're keeping an eye on their own air supplies at the same time and in some cases they are
01:14:12 same time and in some cases they are drawing on the very limits of their physical physiological capabilities so so when assessing or judging the manner in which decisions were made by
01:14:24 in which decisions were made by firefighters and commanders in those circumstances it is our submission that those factors must be borne in mind so I
01:14:35 those factors must be borne in mind so I want to come now to the control room
01:14:46 taken as a body of evidence it is clear in the accounts given by control room operators of their experiences on the
01:14:57 operators of their experiences on the night that the fire brigade control room was overwhelmed by the scale of the incident from an early point in the fire
01:15:10 the operators the the control room officers faced equally difficult of distressing dilemmas to those faced by
01:15:22 distressing dilemmas to those faced by the firefighters inside the building and the brigade acknowledges in relation to the control room that its policies and procedures for the handling of calls the
01:15:34 procedures for the handling of calls the provision of fire survival guidance and the system of communication to and from the fire ground did not provide for an
01:15:45 the fire ground did not provide for an incident on this scale that is one of the most significant lessons which must be learned from the Grenville tower fire and the brigade is learning from it I
01:15:56 and the brigade is learning from it I will come back to what is being done about that in due course as has been stated on a number of occasions the brigade Control Room at Stratford was required to handle more calls this is
01:16:08 required to handle more calls this is the scale of it from residents requiring fire survival guidance within grandpa'll tower on the night of the fire then the total number of such calls in the previous 10 years from the whole of
01:16:20 the previous 10 years from the whole of London that is the difference in the level of scale and the unprecedented nature of what happened on the night and
01:16:31 nature of what happened on the night and that is in the context that certain of the control officers with decades of experience had only been required to handle a handful of fire survival guidance calls in all of their service
01:16:46 we've also learned that so voluminous were the calls to the brigade that it was necessary for a number of other fire services and other emergency services to
01:16:57 services and other emergency services to assist in dealing with them using the established mutual aid arrangements and the demand on the control room on the night of the fire and a number of calls far outstretched anything which the
01:17:09 far outstretched anything which the lepre gauge or indeed any other fire service in the country has ever had to deal with that is a significant consideration of course in trying to understand what happened on the night
01:17:20 understand what happened on the night but the brigade entirely accepts that it doesn't impact on the fact that lessons must now be learned in light of that experience and but in learning those
01:17:37 experience and but in learning those lessons it's essential to acknowledge the real difficulties which control rooms up and down the country will always face in this these circumstances no matter what changes are made that is
01:17:50 no matter what changes are made that is not to say that they cannot something cannot be found to overcome those difficulties but it is very far from being a simple fix among the many issues explored the inquiry looked at the
01:18:03 explored the inquiry looked at the extent to which control room operators should interrogate callers to ascertain the conditions within the immediate the immediate vicinity and outside their flats rather than simply relying on what
01:18:15 flats rather than simply relying on what they say that is an issue which has always presented real difficulties in their training of control staff nationally remote from the fire ground
01:18:26 nationally remote from the fire ground they have no means of carrying out an objective assessment of the conditions of media immediately outside the callers flats or beyond and they're reliant to a very large extent on what they've been
01:18:39 very large extent on what they've been told by a caller and that's one of the key problems which has been described by many of the control officers who gave evidence in this inquiry but it is
01:18:52 evidence in this inquiry but it is perhaps most the problem the issue is most clearly articulated by a resident of Grand
01:18:59 of Grand on the night of the fire it's vividly described by mr. gronkle Otto who lived on the tenth floor who called the fire brigade on a number of occasions on the
01:19:12 brigade on a number of occasions on the night he made two attempts to leave his flat and it found it impossible to do so by reason of the conditions that he faced and in respect of a call back the
01:19:25 faced and in respect of a call back the fire brigade called him back at four forty nine in the morning that was because the control room had spoken to his sister-in-law so there was a call
01:19:36 his sister-in-law so there was a call back mr. Runkle Otto said I can't leave the flat because of the thick black smoke and he was asked by counsel to the inquiry mr. de millet what he would have
01:19:47 inquiry mr. de millet what he would have done if the control operator had told him to leave and get out even though he said he couldn't get out and he said this well I would have assessed again if
01:19:58 this well I would have assessed again if I was in the condition to go out but obviously she would have taken a big responsibility to do so on her behalf because she would know she wouldn't know
01:20:11 because she would know she wouldn't know how bad the conditions outside were I knew she didn't she wouldn't know that was the word of those are the words of mr. gronkle Artie and then in his call
01:20:23 mr. gronkle Artie and then in his call to being brigade control again at 5:05 an hour later during which the control operative operator did instruct him to leave even though he said he cannot get
01:20:34 leave even though he said he cannot get out leave he was told he said that he could not do so and decided to remain where he was but he wanted went on to say this now let's say this is what he
01:20:45 say this now let's say this is what he said in evidence I would be convinced by this person to go out and if something had happened to me how would that person feel if I had not made it out basically
01:20:57 feel if I had not made it out basically so that's why I said and in fact what he said was in that pool someone will have me on their comm if I leave he said that's why I said that you know I don't want to think of
01:21:09 that you know I don't want to think of someone thinking oh because I gave him that advice look what happened to him how would that person then live for the rest of their life now mr. Romm Coolatta was in fact
01:21:22 now mr. Romm Coolatta was in fact rescued from his flat by firefighters at around six o'clock in the morning but in that short passage just that last short passage he captures the essence of the
01:21:33 passage he captures the essence of the challenge which fire services must face in developing policy derive from lessons learned by the Granville Tower or earlier fires that this is not the
01:21:45 earlier fires that this is not the brigade suggesting what we can't do anymore about it it is merely highlighting the genuine and difficult human difficulty that arises in in in developing policy and training on issues
01:21:56 developing policy and training on issues of that fact and as we know the enquiry has heard that many of those who make calls during the fire felt extremely and understandably reluctant to leave their
01:22:07 understandably reluctant to leave their flats mr. Bonifacio being being one so
01:22:19 flats mr. Bonifacio being being one so the lessons which must be learned from control rooms within the UK must be it's animal particularly within London of course must be considered in the context of the enormous scale of the brand phone
01:22:31 of the enormous scale of the brand phone tower fire and the fact that the decision to suspend the stay-put strategy provided by the building design in the building regulations for an entire building was made for the first
01:22:42 entire building was made for the first time in history in the UK and sir in a final section before concluding I just want to highlight if I may the actions
01:22:55 want to highlight if I may the actions which the brigade has taken since the fire and the significant effort which is being put into the process of learning lessons
01:23:04 lessons first of all in interim safety measures
01:23:11 immediately after the 14th of June last year 2017 the brigade was in close liaison with the National Fire Chiefs Council the NFC C for the purpose of
01:23:24 Council the NFC C for the purpose of recommending interim control measures for fire services nationally to mitigate failings in high-rise buildings demonstrating the failings that were seen at Grenville tower the resulting
01:23:37 seen at Grenville tower the resulting guidance was a document produced by the NFC C which recommends a process by which certain types of high-rise residential buildings should be subject
01:23:48 residential buildings should be subject to a risk assessment an analysis by a suitably qualified person and in short form those buildings particularly with ACN cladding and systems similar to the
01:23:59 ACN cladding and systems similar to the Grenville tower fire are now subject to a system certainly in social housing by which it is necessary to develop the possibility of evacuation even before
01:24:12 possibility of evacuation even before the fire brigade get there and that is achieved by trained persons in these buildings who are on duty 24 hours a day as waking watchers who alert in the case
01:24:26 as waking watchers who alert in the case of fire alert the occupants of the building the building occupants are made aware of
01:24:32 aware of evacuation process and that is how that is achieved it's the only way it actually can be achieved when there aren't fire alarms all over the building and an evacuation process so that is the
01:24:43 and an evacuation process so that is the position for fire for buildings which have been identified has been high risk and that's the policy which the N FCC recommends from which the London Fire Brigade that itself adopts but it makes
01:24:56 Brigade that itself adopts but it makes it clear that simultaneous evacute third a simultaneous evacuation strategy for any fire should only be a temporary measure until all the risks have been rectified in addition in London the
01:25:11 rectified in addition in London the brigade has provided for as an interim measure a an increase in the predetermined attendance required for such buildings for an interim period
01:25:22 such buildings for an interim period which increases the number of personnel and fire appliances which will attend a fire in the first instance and further details of that can be found in a document for the organizational review
01:25:33 document for the organizational review which has been disclosed by the by the enquiring importantly though more recently the brigade has now introduced
01:25:45 recently the brigade has now introduced fire escape hoods that are designed to be used by members of the public where they need rescuing through smoke filled environments they provide 15 minutes
01:25:57 environments they provide 15 minutes protection from four of the main fire gases and can be worn by conscious or unconscious persons there now carried on
01:26:08 unconscious persons there now carried on all firefighter breathing apparatus sets and there is also a reserve available if it becomes necessary in a more major incident and importantly the brigade
01:26:20 incident and importantly the brigade together with the Kent Fire Service Fire and Rescue Service are the first fire and rescue services in the country to adopt the use of them in fact they have already proved useful and have been
01:26:33 already proved useful and have been engaged most recently in a fire in which a child was able to leave a second-floor property through the building with
01:26:44 property through the building with with the smoke hood rather than run the risk have been rescued by a ladder there are many instances in which they're useful so that that has been done now there are further actions which I am NOT
01:26:58 there are further actions which I am NOT going to go through in detail but they appear in paragraph 75 30 110 of the brigades statement but I do need to
01:27:10 brigades statement but I do need to touch upon some of them there are several actions and several projects which are now underway to learn the
01:27:21 which are now underway to learn the lessons which have been learned from the night of the fire the accounts which are given in the state and frankly acknowledge where procedures and policies in training fall below the
01:27:32 policies in training fall below the standard required by the brigade and the actions taken to address them it details further actions concerning the use of equipment for firefighting and rescue and an analysis of the work undertaken
01:27:44 and an analysis of the work undertaken to in fact to improve fire ground control communication operational risk information the ORD it is necessary that
01:27:57 information the ORD it is necessary that i say something about that the brigade accepts that the quality of the operational risk information recorded for Grenville tower at the time
01:28:08 recorded for Grenville tower at the time of the fire fell below the standards expected by the brigade as was acknowledged by the London Fire Commissioner during her all air corps Elevens it also points to a wider
01:28:21 Elevens it also points to a wider concern the brigade has in the way that this type of information is gathered recorded and disseminated across the organization the brigades witnesses have highlighted certain issues and practical
01:28:34 highlighted certain issues and practical challenges particularly for fire station personnel in being able to capture all of the information identified in various policies in particular those which are
01:28:45 policies in particular those which are relevant to seven section seven 2d visits familiarization visit
01:28:52 and perhaps in just very briefly touching upon all of those issues those which are perhaps most important having
01:29:04 which are perhaps most important having acknowledged that position so in relation to the operational risk data the brigade is in now in the process of reviewing the way in which
01:29:16 reviewing the way in which familiarization visits under Section 72 t are conducted in relation to policy including the system which governs the way in which risk information is
01:29:27 way in which risk information is gathered recorded and disseminated including also a review of the way in which buildings are assessed the introduction of a scheme by which fire
01:29:38 introduction of a scheme by which fire station staff are provided with increased fire safety knowledge when carrying out 72 D visits also in when carrying out premises risk assessments
01:29:49 carrying out premises risk assessments and operational data base visits so there is a new scheming in development to improve that system and of course a full review of training to reflect all
01:30:01 full review of training to reflect all of those issues the statement for those who wish to read it in more detail also looks at the issues concerned the evacuation of buildings with a stay put
01:30:14 evacuation of buildings with a stay put strategy and the measures which are put in place in relation to that and the recognized need that policy note 633 does not provide specific guidance to
01:30:27 does not provide specific guidance to commanders and firefighters on how evacuation might be achieved and amendments are being looked at for that but I repeat what I said earlier than that is not a simple matter because of
01:30:38 that is not a simple matter because of the nature and design of buildings on incident communications the brigade is reviewing the whole of the communications issue in relation to fire
01:30:50 communications issue in relation to fire ground and control and it is proposed to upgrade those communications both the fire ground radios and for breathing apparation
01:31:01 apparation obviously together with training in relation to brigade control it is right that I repeat that the brigade accepts that it's policies and procedures for
01:31:12 that it's policies and procedures for handling calls the provision of falsifiable guidance and the system of communication to and from the fire ground did not just didn't provide for an incident on this scale and therefore
01:31:24 an incident on this scale and therefore measures are now being addressed to include the expiration of a new dedicated air wave talk group to enable different fire services and different
01:31:35 different fire services and different control rooms to communicate with each other and to effectively exchange communication in case of a major disaster there is to be a revision and is a revision in place of the of the
01:31:47 is a revision in place of the of the fire survival guidance policy 790 fire survival guidance refresher training is being undertaken and a range of other measures measures in connection with
01:31:59 measures measures in connection with that other issues which which those who read the statement will see is that there are reviews of policy concerning high-rise policy firefighting itself
01:32:14 high-rise policy firefighting itself that's all being looked at incident command training is also being looked at particularly in relation to the reinforcement of FSG the the FSG coordinator role on the fire ground and
01:32:26 coordinator role on the fire ground and in relation to the search coordinator Brigade Control and the incident commander all of those issues came sharply into focus in the evidence in phase one sir so in conclusion can I say
01:32:44 phase one sir so in conclusion can I say that the brigade will continue to pursue the actions which is it it has identified in the statement that I've just summarized those those last few issues and where practical will adopt
01:32:57 issues and where practical will adopt measures to address the lessons which can be learned from the Glencoe tower fire it is expected that the inquiry will wish to examine many of those issues further in phase - and the brigade will continue to
01:33:09 - and the brigade will continue to provide every assistance it can to that end but the rubra gay does return to the question imposed in its opening statement back in June as an expression
01:33:21 statement back in June as an expression of the issues with which fire services nationally must wrestle I'm not going to read out that question again but in essence it supposes the simple question whether it is in the public interest to
01:33:33 whether it is in the public interest to make fundamental changes to the building regulation regime the design construction and building control regime so as to ensure that residential
01:33:44 so as to ensure that residential premises particularly high-rise premises are safe so the residents and the public can be confident that they are safe and said that fire services when they intend to deal with fires can be equally
01:33:57 to deal with fires can be equally confident or whether might be and but for the moment I would say or where the fire services should plan across the country to fight fires and carry out
01:34:08 country to fight fires and carry out rescues in buildings which are wholly non-compliant with safety provision if that is so so bit but there are very significant challenges in planning for that some of those challenges are
01:34:20 that some of those challenges are highlighted today those questions are obviously not mutually exclusive sir but it is finally important to bear in mind that fire and rescue services undertake
01:34:31 that fire and rescue services undertake their functions in the built environment on the assumption that it is governed by rigorous regulations robust testing competent individuals making choices about methods of construction and the
01:34:44 about methods of construction and the materials used to ensure buildings are safe whatever changes may be made in fire service policy and there will be that is a commitment which arise from
01:34:57 that is a commitment which arise from the lessons learned in the Grenville tower fire they cannot extend to overcoming the shortcomings in the system of building regulation that is the primary basis upon which fire serve
01:35:09 the primary basis upon which fire serve fire safety is maintained in high-rise residential building and so these are challenging issues which must be scrutinized in Phase two
01:35:20 which must be scrutinized in Phase two but the brigade is well aware that it has its own lessons to learn pointing fingers which simply same as the reality of the position and some of the evidence of phase one has demonstrated that so
01:35:33 of phase one has demonstrated that so for the present the brigade repeats its continuing commitment to the bereaved survivors and residents of Grenville town to do everything in its power to meet their justifiable demand for
01:35:46 meet their justifiable demand for answers to their questions and that meaningful lessons by the brigade some of which have already been identified which i've outlined must be learned from
01:35:58 which i've outlined must be learned from the night of the 14th of June 2017 so those I didn't think I can help you further unless no well thank you very much indeed mr. Walt you've been really
01:36:10 much indeed mr. Walt you've been really economical you should always always be thanked thank you very much but I hope you feel you've covered everything you might I feel as I've given a very full opportunity I'm grateful for itself all right well thank you very much well that
01:36:21 right well thank you very much well that might be a convenient point to have a short break we'll break now ten minutes resume at twenty five to twelve please
01:37:37 you
01:39:21 you
01:49:27 no the next person I'm going to invite to give us a closing statement is the representative chief for which I think for this purpose dismiss bar why is that right yes sir I propose to address you
01:49:47 right yes sir I propose to address you if I may on five matters but before doing so must put my campus emissions into context on the 14th of June 2017 a devastating fire raged through the homes
01:49:59 devastating fire raged through the homes and lives of the grenfell tower residents
01:50:03 residents 72 people died as a result and many more found themselves bereaved and homeless the effects rippled yet more widely as
01:50:14 the effects rippled yet more widely as communities across the UK and overseas reflecting the diversity of the grenfell residents lost friends and relatives I appear before you sir on behalf of the
01:50:27 appear before you sir on behalf of the bereaved those who survived and local residents all of them seeking answers as to how a fire such as this could happen in 21st century London they seek the
01:50:41 in 21st century London they seek the truth and place their trust in you and your team to find it my five topics are first how an inevitable fire overwhelmed
01:50:52 first how an inevitable fire overwhelmed at our second the seminal events of the night in the context of the building third root causes of rapid fire spread forth active and passive protection systems and fifth toxic conditions on
01:51:06 systems and fifth toxic conditions on the night I will conclude with findings we invite the inquiry to make turning first to the inevitability of the fire and the towers ability to withstand it
01:51:18 and the towers ability to withstand it the travesty of grenfell is that the fire which overwhelmed it is one which its design contemplated and could easily have resisted due to its concrete
01:51:30 have resisted due to its concrete compartment ation which was originally calm
01:51:33 calm mented bio concrete facade professor torero described the fire which he calculates was no bigger than a frying pan fire as an inevitable perfectly
01:51:44 pan fire as an inevitable perfectly foreseeable event with a probability of 1 in other words bound to happen from the moment Grenfell tower was enveloped in patently non-compliant
01:51:55 enveloped in patently non-compliant cladding materials which would both ignite easily and burn rapidly it's fire safety strategy which depended on the state put principle and in turn on
01:52:07 state put principle and in turn on compartment ation became invalid and dangerous all three fire experts agree that once the building was clad in this particular cladding system a stay put
01:52:20 particular cladding system a stay put policy was no longer appropriate it is clear from the experts evidence that the installation of this particular cladding system so complex that its performance
01:52:31 system so complex that its performance cannot be properly precisely assessed inexorably led to the disaster that followed as dr. Lane forcefully put it grenfell tower should never have been
01:52:43 grenfell tower should never have been handed over after the refurbishment with this rain screen system given the stay-put policy the tower represented a health hazard so egregious it should
01:52:55 health hazard so egregious it should never have been occupied given the combination of fire inevitability coupled with a stay put policy it is no exaggeration to describe the tower as
01:53:07 exaggeration to describe the tower as refurbished as a deathtrap as indeed our clients did describe it my second topic is the seminal events of the night professor Toreros four stages the four I
01:53:23 professor Toreros four stages the four I outline each stage we should bear in mind Professor Toreros observation that the defining characteristic of a high-rise building is that the timescales of allowing people safe time to exit will converge with the time in
01:53:36 to exit will converge with the time in which parts of the building will fail and that fire safety strategies assume parts will fail but that the escape remain safe the first stage is breech of
01:53:48 remain safe the first stage is breech of the compartment of flat 16 between zero 54 to 105 or 113 first how was the compartment of flat 16 breached the two
01:54:00 compartment of flat 16 breached the two most probable routes by which fire escaped flat 16 and entered the cladding or either through the window surround once the uPVC has fallen away or through the extractor fan or window all three
01:54:13 the extractor fan or window all three fire spread experts agree that the most probable route is by the defamation or falling away of the uPVC surround the you PVC which professors torero
01:54:24 you PVC which professors torero and abyss b agree loses its mechanical strength at low temperatures within 5 to 11 minutes served as a single barrier between the interior of the tower and
01:54:36 between the interior of the tower and the components of the cladding system the experts agree that the falling away of the uPVC likely occurred first exposing a complex system of combustible
01:54:47 exposing a complex system of combustible materials to heat and smoke facilitating ignition beyond that we are unlikely ever to know the precise sequence in which the materials burned and as
01:55:00 which the materials burned and as Professor Burt torero said the importance to the overall outcome of what was the first thing to catch fire is probably not that significant dr.
01:55:11 is probably not that significant dr. Lane considers the fire exited the top of the window by the column professors torero and Bisbee also favored this route although they approach it by different but complementary analyses
01:55:22 different but complementary analyses professor torero uses fire dynamics and professor Bisbee analyzes images to determine the sequence of ignition of the cladding professor Toreros stress
01:55:33 the cladding professor Toreros stress that both analyses had to be considered the alternative route by of ignition by smoke venting from the window is not a likely scenario professor torero is satisfied this was
01:55:46 professor torero is satisfied this was not the means of escape since the temperature of smoke venting from the flat 16 window was insufficient to cause fire in the aluminium panels
01:55:57 fire in the aluminium panels the properties of any given material did not indicate which would ignite first while so's with low thermal inertia will ignite faster much faster it depends
01:56:08 ignite faster much faster it depends where each material was in relation to the flame further the contribution of exposed polyethylene edges of the R conic aluminium cladding panels will
01:56:19 conic aluminium cladding panels will have changed the outcome in that they will ignite faster than other areas of the panel but given the proximity of other materials it is impossible to identify the significance of that except
01:56:32 identify the significance of that except perhaps at this at the crown the experts are agreed that in the event of any fire starting near a window there was a high probability of fire spread into the
01:56:43 probability of fire spread into the cladding the second question during this first stage is when was the com-pub compartment breached there are two competing views whichever view is accepted as correct
01:56:55 whichever view is accepted as correct all three experts agree that the fire had breached the compartment between 105 and 113 and had very obviously breached the compartment by between 111 and 113
01:57:10 taking the two alternative definitions of compartment breach in turn the first is that it occurs the moment the fire leaves the compartment and enters the cladding professor Toreros view is that
01:57:23 cladding professor Toreros view is that the compartment is breached at a defined moment in time namely when the fire is within the cladding outside flat 16 which he says occurred between 105 and
01:57:34 which he says occurred between 105 and 108 and was fairly obvious by 111 professor Bisbee was willing to accept at grenfell because of the inevitability of fire spread that the compartment was
01:57:45 of fire spread that the compartment was breached at the moment when the fire was in the cladding outside flat 1600 on his reckoning 109 the alternative definition of compartment breach is that it occurs
01:57:56 of compartment breach is that it occurs only when the fire enters another flat dr. lanes view is that from the perspective of a DB compartment ation is not
01:58:06 not assumed to have been breached until the flame is in the next compartment and on this basis compartment ation is breached at 1:30 dr. Lane relied on diagram 33 of
01:58:18 at 1:30 dr. Lane relied on diagram 33 of a DB but a DB implies that compartment ation is breached simply on spread beyond the compartment of origin once the fire is in the cladding it is by
01:58:30 the fire is in the cladding it is by definition no longer within the compartment of origin once compartment ation is breached evacuation is the only viable option
01:58:41 evacuation is the only viable option professor torero is clear that once compartment ation is breached evacuation is necessary to secure the safety of the residence and is the only viable option at that point that is because stay put
01:58:56 at that point that is because stay put depends on early extinction of the internal fire namely the tactics known as defend in place which dr. Lane defined in her first report as meaning
01:59:07 defined in her first report as meaning early extinction of the fire once that early effort has failed the stay-put practice strategy must change to evacuate the fact that in the past as
01:59:20 evacuate the fact that in the past as mr. Welsh told us this morning the brigade is ignored a breach of compartment ation by sector ization and has managed to extinguish the fire does not alter these fundamental principles
01:59:33 while dr. Lane was unwilling to say that stay-put had failed at the moment compartment ation was breached she accepted a high degree of compartment ation was needed to support a stay put
01:59:46 ation was needed to support a stay put strategy and if that cannot be achieved a total evacuation is highly likely to be needed on her view compartment ation had been breached at 1:13 but stay put
01:59:59 had been breached at 1:13 but stay put did not substantially fail as she put it until 1:26 which she chose because by then 20 flats were visibly on farm dr. Lane appears to have had in mind the
02:00:11 Lane appears to have had in mind the point at which the firefighters ought to have perceived the failure is stay put in fact the firefighters perceived that defend in place on which stay put
02:00:22 defend in place on which stay put depends had failed by 113 since at that time the brigade ordered a hydraulic platform which is only consistent with external firefighting as dr. Lane said
02:00:35 external firefighting as dr. Lane said in her evidence that was a recognition that unplanned for external firefighting is becoming necessary I now move on to
02:00:46 is becoming necessary I now move on to stage two vertical fire spread up the east face
02:00:50 east face 105 or 113 to 129 vertical spread at groennfell took approximately 12 to 15 minutes and averaged four meters per minute that rate of spread puts grenfell
02:01:04 minute that rate of spread puts grenfell among the slowest of 12 international adding fires examined by Professor torero from the early stages so 113 to 160 the fire had spread along the tip
02:01:16 160 the fire had spread along the tip and edges of column B 5 during vertical flame spread the flame propagated laterally northwards but not southwards between 118 and 128 the
02:01:29 southwards between 118 and 128 the vertically propagating fire had already ignited internal fires on the fifth twelve and twenty second floors combustion within the cavity in the
02:01:41 combustion within the cavity in the column and in the cavity behind the spandrels is considered by the experts to be complex and we may never know the precise mechanism what we do know is that the flames elongate as they seek
02:01:54 that the flames elongate as they seek oxygen and fuel leading to flame extension of five to ten times that of the expected lengths of an unenclosed fire and the fuel rich cavity is kept hot by the insulation the complexity of
02:02:08 hot by the insulation the complexity of the way the insulation interacted with the polyethylene within the cavity is also significant as I will explain shortly
02:02:16 shortly professor torero tells us that the width of the cavity is fundamental to determining the extent to which the cavity
02:02:24 cavity acted as chimneys now if the width of the cavity is either too great or too small then the fire dies out during the second phase residents fled the flat
02:02:36 second phase residents fled the flat sixes and in this phase the lobbies and stairwell appear to have been relatively smoke-free the second stage was what professor purser describes as the golden
02:02:47 professor purser describes as the golden early period during any fire when people can make a safely escape and after which the fire gets exponentially worse the third stage is compromised of the
02:02:59 third stage is compromised of the interior between 109 to 150 or two o'clock this stage began when the fire reached the top of the East face and began to spread laterally by means of
02:03:10 began to spread laterally by means of the crown the crown was responsible for one of the very unusual features of the grenfell fire namely that horizontal spread enveloped the entirety of the building within less than three hours
02:03:23 building within less than three hours the crown described by professor Bisbee as essentially a fuse around the top of the building was a wholly unnecessary architectural feature whose sole
02:03:34 architectural feature whose sole function was aesthetic its contribution to lateral fire spread was however devastating taking 24 lives from the 23rd floor alone to say nothing of the
02:03:46 23rd floor alone to say nothing of the many lives lost on the floors below caused by fires starting by dripping materials from the crown the crown was made purely of our conic cladding panels
02:03:58 made purely of our conic cladding panels shaped into fins and without insulation behind them the rate of lateral spread at the crown was half a metre per second setting the pace for lateral propagation
02:04:10 setting the pace for lateral propagation lateral spread at the crown was significant for two particular reasons first it effectively compromised the level the flats above level 20 the rate
02:04:21 level the flats above level 20 the rate at which those flats were penetrated was at a similar rate to the progression of fire in the crown these flats suffered from heating melting and dripping of polyethylene from
02:04:32 polyethylene from crown ii the crown drove horizontal and vertical spread elsewhere over the building melting and burning polyethylene and molten debris from the
02:04:45 polyethylene and molten debris from the crown fell to lower levels in uniting fires which propagated vertically upwards the phenomenon of falling burning debris was also the key mechanism of horizontal spread at the
02:04:57 mechanism of horizontal spread at the lower levels it is tempting to think that solely the are conic panels were responsible for the devastating effects of rapid lateral spread caused by the
02:05:09 of rapid lateral spread caused by the crown since there was no insulation behind the fins it must be remembered however that the melting dripping polyethylene fell into the insulation and other materials in the cladding so
02:05:23 and other materials in the cladding so whilst the speed of lateral spread at the crown clearly implicates our conic panels as being the most significant cause of rapid fire spread in terms of lies lost as a result of the crown the
02:05:36 lies lost as a result of the crown the other materials also played a role the arrangement of materials around windows is also important in this phase as in other phases of the fire as it provided
02:05:48 other phases of the fire as it provided a means for the external fire to re-enter the flats heat fluxes generated by the fire would impose thermal loads an order of magnitude greater than the
02:05:59 an order of magnitude greater than the components were designed to tolerate and which would inevitably cause a failure of the window glazing the extract fans and the uPVC windows around allowing
02:06:10 and the uPVC windows around allowing flame to re-enter during this third phase evolution of conditions in the stairs and the lobbies is very dynamic communal stairwells and lobbies on
02:06:23 communal stairwells and lobbies on levels 10 to 14 and above level 20 intermittently become actually or seemingly impossible to occupants by about 150 another key feature of this
02:06:36 about 150 another key feature of this third phase is that smoke spread from the east to the west face of the tower relatively early 1:57 at this time the flame front had
02:06:47 1:57 at this time the flame front had not yet reached the west of the tower suggesting a breach already of two layers of compartment ation the opening of doors and the doors failure to close
02:06:59 of doors and the doors failure to close appears to have played a key role in the loss of compartment ation and smoke spread during this phase but further investigation is required the
02:07:10 investigation is required the convergence of timescales that I talked about earlier also becomes particularly acute in this third phase as the towers safety systems are failing limiting the
02:07:21 safety systems are failing limiting the opportunities for residents to evacuate the stairs and lobbies are affected by firefighting activities bringing firefighters into conflict with the residents need to escape finally
02:07:34 residents need to escape finally professor torero identifies his fourth stage the untenable stage - until the extinction of the fire professors torero and identified sorry professor errors
02:07:47 and identified sorry professor errors and Persa define unten ability is a combination of physiological and behavioral conditions both observe that although conditions in the stairs were often perilous during this period they
02:07:59 often perilous during this period they were variable such that escapes were possible even after 3 a.m. my third topic is the causes of failure of the tower the root cause of the
02:08:12 of the tower the root cause of the failure of the tower is the facade and the window assemblies I turn first to the question of how compliance of the facade and windows is to be achieved under the building regulations
02:08:24 under the building regulations functional requirement be for one of the regulations requires that the external walls shall adequately resist the spread of fire over the walls having regard to the height use and position of the
02:08:37 the height use and position of the building non-mandatory guidance on how this functional requirement can be achieved is given in the form of a approved document b which i'll call ad b there are two principal routes for
02:08:49 there are two principal routes for compliance suggested by ad b either the large-scale test or the so called prescriptive route the third route is a holistic fire safety
02:09:00 third route is a holistic fire safety assessment of the building and Industry suggests a fourth route might be a desktop study as there is no evidence of any route to compliance having been
02:09:12 any route to compliance having been followed the prescriptive route was adopted by default by the gren failed contractors and design team that route sets requirements for insulation and
02:09:23 sets requirements for insulation and outer surfaces of external walls by reference to national and european standards and requires proof of compliance by product certificates no
02:09:34 compliance by product certificates no certificates were however provided dr. Lane has identified the reaction to fire classification which the product should have met by reference to the european
02:09:45 have met by reference to the european standard BS en one three five zero one which classes products as a one described as non combustible a two known in the national system as products of
02:09:57 in the national system as products of limited combust ability or below a1 and a2 classes be down to F as can be seen from dr. Lane's table at figure F four of her report
02:10:08 of her report there are similarly low limits of thermal energy output imposed on both a 1 and a 2 but there are no such limits on classes B to F both a1 and a2 can
02:10:22 on classes B to F both a1 and a2 can pass the non combustible a t-test bs11 8 to though to achieve a 2 that is not necessarily required the relative flammability of a1 and a2 as against
02:10:36 flammability of a1 and a2 as against classes B to F products undoubtedly matters in terms of the ease of ignition and rate of burning at grenfell the insulation should by reference to ADB
02:10:49 insulation should by reference to ADB have been minimum a 2 s 3 D 2 the insulation products in fact used were not in the same league and ranged from
02:11:00 not in the same league and ranged from European classes D down to F where test evidence was even available the ACM cladding panel services should have been class zero national system or
02:11:13 have been class zero national system or European class bs3 d2 or better but there is no valid certificate supporting any such grading our conics rainer bond
02:11:24 any such grading our conics rainer bond PE 55 cassette system was european class ii but even then only when tested with a class a tooth substrate that means being
02:11:35 class a tooth substrate that means being tested up against a piece of a2 absent that protection and at Grenfell that protection was absent one assumes that rana bond would have achieved a yet
02:11:47 rana bond would have achieved a yet lower classification than classy as i said in opening the g4 will submit in phase two that the core of the panels should have been of limited combust
02:11:58 should have been of limited combust ability given the functional requirement of the building regulations and a DB at Grenfell the core of the panels equated as professor Bisbee in his first
02:12:10 as professor Bisbee in his first presentation showed us two diesel or lighter fuel and is openly referred to by industry as petrol dr. Lane considers that not one of the materials in the
02:12:22 that not one of the materials in the facade complied with a DB or was compliant with the building regulations professor Bisbee is equally adamant that functional objective b4 was clearly not
02:12:33 functional objective b4 was clearly not achieved at Brent felt are the consequences of this non-compliance was that the fire would spread the spread would be rapid and once in the cladding
02:12:44 would be rapid and once in the cladding nothing could impede the spread of smoke and fire as professor Bisbee said if a fire is ignited in a cladding system such as this made from materials such as
02:12:56 such as this made from materials such as these under any circumstances we have to expect it to spread quickly and catastrophically because of the nature of the materials involved
02:13:08 of the materials involved I turn next to the windows starting with the uPVC linings of the sill head and sides of the windows on the interior of the tower all three experts acknowledge
02:13:20 the tower all three experts acknowledge the alarmingly low temperature at which uPVC loses mechanical stiffness these uPVC surrounds demonstrate the complexity of fire engineering design on
02:13:32 complexity of fire engineering design on the one hand the material is fire retardant with a high ignition temperature on the other hand it deforms a very low temperature whilst dr. Lane
02:13:43 a very low temperature whilst dr. Lane will be more concerned about what lay beneath the uPVC than the material itself
02:13:48 itself professor Bisbee noted if you are relying on this material to provide any sort of performance in a fire you ought to be deeply suspicious of the ability
02:13:59 to be deeply suspicious of the ability to provide it the uPVC surrounds acted by default as cavity barriers between the interior of the window and the cavity of the cladding uPVC is wholly
02:14:12 cavity of the cladding uPVC is wholly unsuitable as a cavity barrier given its propensity to melt and should not have been used no property cavity barrier was designed even though they are required at Windows accordingly the window
02:14:25 at Windows accordingly the window assembly was not compliant with ADB nor functional requirement be 3/4 of the regulations which requires that the building shall be designed and constructed so that the unseen spread of
02:14:38 constructed so that the unseen spread of fire and smoke within the concealed spaces in its structure and fabric is inhibited the BRE report of 1992 to
02:14:49 inhibited the BRE report of 1992 to government following the knowsley Heights fire cautioned against the use of uPVC near polymeric materials such as the polyethylene or insulation given the
02:15:00 the polyethylene or insulation given the known toxicity of uPVC sufficient at grenfell to intoxicate within approximately 13 minutes according to Professor purses estimation it is
02:15:11 Professor purses estimation it is remarkable that they are used at a recognized point of fire reentry namely the windows what is clear at groennfell is the material was being relied on as a
02:15:22 the material was being relied on as a cavity barrier even though incapable of being one there were five key failings in the design of the window assemblies according to dr. Lane first the windows
02:15:34 according to dr. Lane first the windows were pushed outward compared to the originals this brought two specific gaps within the internal wall construction both of which were a potential path of fire spread second the infill panels
02:15:46 fire spread second the infill panels between the windows were clad with ellu glaze insulating panels containing styrofoam given that this is insulation it should have been limited combust
02:15:57 it should have been limited combust ability or a - the evidence suggests in fact it was as low as Class E third a void was left between the original
02:16:08 void was left between the original concrete and the alyou glaze infill panels which provided a route for fire spread forth the windows were reduced in size leaving a 30 to 120 millimeter gap
02:16:20 size leaving a 30 to 120 millimeter gap between the sides of the windows and the column which was covered with an EPDM membrane backed with insulation the insulation materials were Plast E and F
02:16:31 insulation materials were Plast E and F instead of limited combustibility the EPDM led directly onto the insulation in the cap cladding cavity and could be burned rapidly through v the window
02:16:44 burned rapidly through v the window surrounds contained highly combustible materials including the original wooden sills and internal wood lining and the per board above and below the windows in
02:16:55 per board above and below the windows in summary as dr. Lane said the type of reveal lining materials and how they were arranged provided no means to control the spread of fire and smoke
02:17:06 control the spread of fire and smoke they had known or at best very little fire resisting performance turning back to the facade as a whole it's important to bear in mind that the components of
02:17:18 to bear in mind that the components of the facade function together the materials interact in ways that are not predictable and this may be exacerbated further by geometry to create what dr. Lane described a perfect
02:17:30 Lane described a perfect Bastien process this means that when considering the facade we cannot view the materials in isolation it does not however absolve any of the materials each played their role I now consider
02:17:44 each played their role I now consider the role of our conics Reina bond PE 55 smoked silver aluminium panels the polyethylene within our conics aluminium
02:17:56 polyethylene within our conics aluminium panels which as I have said equates to lighter fuel had devastating consequences for vertical and horizontal flame spread around the crown the experts agree on particular dangers
02:18:08 experts agree on particular dangers posed by this product dr. lane considered it contributed to the most rapid of the observed fire spread professor Bisbee noted the reaction to
02:18:19 professor Bisbee noted the reaction to fire of thermoplastic polymers including polyethylene is well known and documented and has been since the 1980s its behavior cannot be considered surprising by any competent fire safety
02:18:32 surprising by any competent fire safety professional professor Bisbee considered the role of the polyethylene is particularly important overshadowing the effect of the insulation professor
02:18:43 effect of the insulation professor torero
02:18:44 torero observed that due to the polyethylene being thermally thin once ignited it will spread at a much faster rate than PIR insulation the aluminium skins which
02:18:55 PIR insulation the aluminium skins which melt and typical fire temperatures provided no protection against the polyethylene within it due to the extensive exposed polyethylene edges and given the polyethylene melting causes
02:19:08 given the polyethylene melting causes splitting of the aluminium when considering the behavior of the Rana bond panels it's important to consider the role of the PIR insulation there
02:19:19 the role of the PIR insulation there were two types of insulation used on the facade Celotex RS 5000 Class D and kingspan cool therm k 15 for which there was no test evidence the Celotex product
02:19:32 was no test evidence the Celotex product was PIR the kingspan product was phenolic foam but professor Bisbee considers its behavior in flames similar to PIR neither were anything approaching
02:19:43 approaching combust ability while the experts were clear on the primacy of polyethylene as a means for fire spread the insulation clearly did have a contribution but the
02:19:57 clearly did have a contribution but the extent is more difficult to measure professors torero and Bisbee were however clear that the low thermal inertia of PIR which was lower than the other elements of the cladding will lead
02:20:10 other elements of the cladding will lead to much faster ignition of the PIR the PIR also performed a very effective supporting role to the polyethylene first because its mass was greater than
02:20:22 first because its mass was greater than the polyethylene or the other combustibles hence it represented a large amount of fuel and could burn for longer than other materials second the combustion of polyethylene and PIR is
02:20:35 combustion of polyethylene and PIR is not mutually supportive through a process called radiative feedback that meant the PIR s insulating capability prevented heat loss and its release of
02:20:46 prevented heat loss and its release of pyrolysis products assisted acceleration of upward flame spread even though polyethylene was the main driver of upward spread in short whereas polyethylene determines the
02:20:58 whereas polyethylene determines the speed at which the fire propagates the role of the PIR dick Nate's dictate speed of ignition and duration of burning while both products pose their
02:21:10 burning while both products pose their own particular dangers these dangers were amplified by their interaction with each other as I have said the insulation should all have been a - or limited
02:21:22 should all have been a - or limited combust ability but in fact ranged between classes D down to F given the extent of the inferno which ensued it may be suggested that as a matter of
02:21:33 may be suggested that as a matter of causation it was irrelevant whether the insulation was of limited combust ability because it would have burned anyway that argument overlooks the
02:21:44 anyway that argument overlooks the fundamental point of Professor Toreros convergence of timescales had the insulation used been of limited combust ability it would not have ignited or burn
02:21:54 burn quickly particularly at the outset potentially enabling the brigade to extinguish the fire before it took hold in the facade and or enabling residents
02:22:05 in the facade and or enabling residents to evacuate in time the particular properties and classification of materials not merely the binary question of whether they are combustible or not
02:22:16 of whether they are combustible or not combustible is important this is obvious in many ways for example materials such as aluminium are not combustible but they do melt so you cannot design safely
02:22:28 they do melt so you cannot design safely for fire merely by focusing on combust ability an example of that point is the cavity barriers while there were a number of defects in the way the side rise cavity barriers were installed
02:22:40 rise cavity barriers were installed evidencing appalling workmanship that is a secondary issue to the real problem namely fundamentally flawed design cavity barriers would never have assisted in a facade system of this
02:22:53 assisted in a facade system of this nature given the outer wall of the cavity contains combustible polyethylene and the aluminium itself will deflect and melt what is worse in an
02:23:04 and melt what is worse in an illustration of the complexity of fire Engineering in facade systems cavity barriers could actually have been a mechanism of fire spread in that they created ledges on which the fires could
02:23:15 created ledges on which the fires could sit I now turned my fourth topic the internal active and passive safety measures the purpose of active and passive safety measures was to protect
02:23:27 passive safety measures was to protect the stairs and lobby and the residents of other flats as we've heard from the residents the key passive and active systems failed drastically even when one
02:23:38 systems failed drastically even when one considers that they were only designed to mitigate a fire on a single floor the abject failure of the design of grenfell Tower is evidenced by first the doors
02:23:50 Tower is evidenced by first the doors which failed to close or prevent smoke spread thereby undermining compartment ation second the sheer perversity of a ventilation system which appears designed to suck smoke into the
02:24:03 appears designed to suck smoke into the lobbies the very thing it is supposed to protect third a lift which bore the hallmarks of a fire lift but which in fact was to all intents and purposes an
02:24:15 fact was to all intents and purposes an ordinary lift in each case it should be remembered that the building regulations do not automatically apply to the carrying out of replacement of such systems within an existing building the
02:24:28 systems within an existing building the regulations only apply if the works are a material alteration namely either they have the effect of making work non-compliant where previously it complied or making us previously non
02:24:41 complied or making us previously non compliant system yet more unsatisfactory starting with the doors there is clear evidence that doors may have failed to provide the degree of compartment ation
02:24:53 provide the degree of compartment ation required since very significant smoke spread was experienced at a relatively early stage including the possible movement of spoke through two compartments dr. Lane has assessed both
02:25:07 compartments dr. Lane has assessed both flat and stair doors as two flat doors 106 were replaced in 2011 but 14 were not these 14 were all lost in the fire
02:25:18 not these 14 were all lost in the fire and dr. Lane is unaware of their specification and so cannot confirm whether they complied with the applicable requirements the 2011 replacement doors were master door sha
02:25:30 replacement doors were master door sha doors dr. Lane finds they didn't comply over then current standard because the tests did not demonstrate 30 minutes integrity a critical failing of the
02:25:42 integrity a critical failing of the doors was the lack of functioning self closes the DC LG sleeping guide and LG a guide both require self closes dr. Lane identifies a systemic problem of
02:25:55 identifies a systemic problem of malfunctioning self closing devices the evidence suggests an alarming failure by TMO to repair or replace door closes dr.
02:26:06 TMO to repair or replace door closes dr. Lane will investigate the precise nature of smoke spread through the flat doors flat and per Lobby to ascertain the contribution of each door turning to the stair doors these are the
02:26:18 turning to the stair doors these are the originals but dr. Lane has established that they were not the type to door required by CP 371 instead they were British standard fire check doors which
02:26:29 British standard fire check doors which provided only 20 minutes integrity as opposed to the 30 minutes required of type 2 doors fire risk assessments carried out in 2016 identified instances
02:26:41 carried out in 2016 identified instances of self closing devices on stair doors not functioning dr. Lane has seen no evidence that such issues were resolved before the fire the second issue I'm going to consider
02:26:52 the second issue I'm going to consider is a smoke ventilation system dr. Lane hasn't yet reached a conclusion on whether the system is compliant or not but we'll do so in phase 2 the system
02:27:03 but we'll do so in phase 2 the system was a depressurization system which should have the extracted smoke from the flats themselves in fact it appears the design would pull smoke from the flats into the models thirdly the lift the
02:27:17 into the models thirdly the lift the original lifts were required by CP 3 1971 to be fire lifts these were replaced in 2005 by which time a DB 2000 required the provision of firefighting
02:27:29 required the provision of firefighting shafts with firefighting lifts in buildings over 18 metres it is only fire fighting lifts which can be used for evacuation fire lifts do not have the
02:27:41 evacuation fire lifts do not have the requisite emergency power source or protection despite the requirements of a DB 2005 the lifts were not upgraded to firefighting lists furthermore they were
02:27:53 firefighting lists furthermore they were not even fireless they merely masqueraded as violence because dr. Lane has found no evidence that the lifts were ever connected to fire control switches in 2005 when upgraded and
02:28:06 switches in 2005 when upgraded and neither of the two fire control switches functioned on the night this is all the more astonishing given the TM owes policy expressed in its fire safety
02:28:17 policy expressed in its fire safety strategy of upgrading lifts to fire lifts
02:28:22 lifts equally shocking is the misdescription in that document of the grenfell lifts as firefighting lifts dr. Lane makes no conclusive finding of non-compliance of
02:28:33 conclusive finding of non-compliance of the lift but her provisional view given the failure to provide firefighting lifts under adb 2000 is that functional requirement b5 was not met my final
02:28:45 requirement b5 was not met my final topic is toxic smoke conditions generated by the burning of the polymeric materials or flat contents first irritant and asphyxiant gases
02:28:56 first irritant and asphyxiant gases likely to have been produced as Professor purser stressed his analysis is purely indicative at this stage there is limited data from the far beyond the
02:29:07 is limited data from the far beyond the fatalities including the toxicology records from 15 of the deceased all of whom showed high levels of carboxyhemoglobin described as Co HB co
02:29:19 carboxyhemoglobin described as Co HB co h b levels in human tissue evidences inhalation of carbon monoxide professor purser considers those who died at Grenfell are likely to have died from
02:29:30 Grenfell are likely to have died from toxic gases not burns the two people who may have fallen also showed Co HB levels which indicated they had had a
02:29:41 which indicated they had had a significant dose of carbon monoxide and quite significant smoke over a long period
02:29:49 period professor purser identifies three fuel packages of interest based on generic polymer materials in the cladding windows and flat contents he has calculated the yields of
02:30:00 he has calculated the yields of asphyxiant gases carbon monoxide and hydrogen cyanide which he thinks are likely to have been produced professor purser suggests a tentative three-stage sequence of how toxic gases
02:30:13 three-stage sequence of how toxic gases may have penetrated flats first he suggests a slow minor infiltration of smoke from the exterior smoke plume derived from the cladding he concludes
02:30:25 derived from the cladding he concludes that polyethylene at grenfell did not produce sufficient carbon monoxide to be toxic but would generate dense smoke so being able to see 25 centimeters ahead of you in the flat
02:30:38 25 centimeters ahead of you in the flat and by inference in the lobby's second professor person considers dense toxic smoke followed by flame from the exterior PIR around the windows would
02:30:49 exterior PIR around the windows would rapidly penetrate flats through voids the PIR would have produced large quantities of carbon monoxide and hydrogen cyanide and likely resulted in
02:31:00 hydrogen cyanide and likely resulted in collapse after 23 minutes third the uPVC windows surrounds might have yielded sufficient carbon monoxide and hydrogen cyanide to cause collapse
02:31:11 and hydrogen cyanide to cause collapse within 30 minutes this sequence leads professor purser to conclude that toxic gases penetrating a flat in the minutes before the flat contents became involved presented a
02:31:24 contents became involved presented a substantial hazard although professor Percy's evidence is necessarily tentative it is rooted in data applied by him conservatively it is reasonable
02:31:35 by him conservatively it is reasonable to conclude that conditions in flats lobbies and stairs were highly toxic and that toxicity in the first few minutes of each flat fire was driven by the
02:31:46 of each flat fire was driven by the materials from the cladding and window surrounds as Professor purser tells us even if smoke is not toxic at all it influences behavior and determines
02:31:58 influences behavior and determines whether people live or die to conclude the facade which included the crown patently did not adequately
02:32:09 the crown patently did not adequately exist and on the contrary promoted flame spread and so was in breach of the Building Regulations the facade including its crown lack of cavity barriers around windows which could have
02:32:22 barriers around windows which could have prevented initial fire escape together with the doors and lifts are all contributors to the scale of the disaster and therefore two lives lost
02:32:33 disaster and therefore two lives lost the g4 seeks findings on behalf of those who have lost their loved ones those who have survived the fire and all those for whom grenfell was there
02:32:44 whom grenfell was there that the facade and window assemblies did not comply with the building regulations the inquiry is able to and should make these findings at phase one
02:32:57 should make these findings at phase one on the clear evidence of the experts particularly dr. Lane and also professors torero and Bisbee regarding the building many of the corporate CPS
02:33:08 the building many of the corporate CPS agree that findings of non-compliance of the facade should be made our BK c t-- mo and kingspan all invites such findings l FB FB you and FAA assert
02:33:20 findings l FB FB you and FAA assert non-compliance and C s Stokes says it does not dispute that the facade was non-compliant the inquiries should not be deterred from making findings of
02:33:32 be deterred from making findings of non-compliance on the basis of exhortation x' from ridin far conic and Celotex not to make such findings on the grounds they would be premature
02:33:43 grounds they would be premature these corporates simply wish despite the 72 deaths to keep kicking the can down the road the inquiry has
02:33:54 the can down the road the inquiry has long made clear the doctor fector lanes Phase one report would Express a preliminary review as to the towers compliance with regulations dr. Lane has expressed the unequivocal opinion based
02:34:06 expressed the unequivocal opinion based on extensive investigations that the facade and each of its components were not compliant attempts fire conic ridin and Celotex to undermine that clear
02:34:18 and Celotex to undermine that clear finding by suggesting that the evidence to date is to provisional or that the cause of the fire nature and roots of fire spread are not entirely clear
02:34:29 fire spread are not entirely clear should be ignored an example of the corporates obfuscation is that our conics position appears to have inexplicably changed from its opening
02:34:40 inexplicably changed from its opening statement at that time it admitted that if the prescriptive route to compliance subscribe then its panels should on one view have been of limited combust ability and it said patently were not
02:34:54 ability and it said patently were not it is now clear that the prescriptive route was adopted by default and in any case given the evidence that far from resisting flame spreads the facade
02:35:05 resisting flame spreads the facade promoted it it is demonstrably non-compliant with building regulations our Connick however now avoids recognizing the non-compliance of its
02:35:17 recognizing the non-compliance of its product and instead complains that it was not only its product which caused a disastrous fire our Connick submits it was only the use of a CMP e in
02:35:29 was only the use of a CMP e in combination with the other materials that created the conditions for the catastrophe we submit that it is clear that our conics Raina bonky panel was
02:35:40 that our conics Raina bonky panel was primarily responsible for the rapidity of fire spread but equally clearly the insulation and other components of the cladding played a role in order to reach
02:35:53 cladding played a role in order to reach a finding that the cladding system was non-compliant it is not necessary for the inquiry to know the precise contribution of each material to the catastrophe we also know
02:36:06 material to the catastrophe we also know that even now Bryden does not submit that its work was compliant with the building regulations and indeed no one suggests the facade complied given dr.
02:36:17 suggests the facade complied given dr. lanes unequivocal evidence that the facade did not comply the silence of Ryden and others on this point is tantamount to an admission that its facade was non-compliant accordingly we
02:36:31 facade was non-compliant accordingly we invite you to find that the facade and window assembly was non-compliant with the building regulations those are my submissions thank you very much indeed
02:36:46 right yes mr. Friedman take up the baton at this point
02:36:58 so if I may the plan is to be 45 minutes and so can I ask you and your shorthand writers if you might sit a little into the lunch in a German and they're very
02:37:10 the lunch in a German and they're very willing and expecting mine too much if it enables you to finish that would be sensible I agree I'm grateful sir what would bereaved and surviving
02:37:24 what would bereaved and surviving residents want and need from this inquiry is a fearless reckoning with what went wrong and what must be different in the future I'm going to
02:37:38 different in the future I'm going to deal with inquiry law an overview of the emergency response which my other colleagues will develop in more detail today and tomorrow and conclude with the residents the purpose of any public
02:37:52 residents the purpose of any public inquiry lies in the statutory trigger for its establishment this is dealt with in Section one of the inquiries Act 2005 it requires an event that has caused
02:38:05 it requires an event that has caused such public concern in the words of the statute as to make a minister conclude that an independent process of fact-finding and recommendations is the
02:38:17 fact-finding and recommendations is the only viable means to restore public confidence the ensuing process of accountable learning in public is a major feature of any democracy when
02:38:30 major feature of any democracy when things go profoundly wrong it constitutes a recognition that neither the ordinary processes of parliament or government nor conventional forms of justice through the courts would be
02:38:42 justice through the courts would be sufficient to vindicate the interests of the immediate victims and wider society for the bereaved and survivors and residents the force of that imperative
02:38:55 residents the force of that imperative has not lessened since this enquiry began it has only grown stronger enquiries are tribunals of truth and
02:39:07 enquiries are tribunals of truth and responsibility not liability the distinction is reflected with great nuance in section 2 of the inquiries and it first declares that an inquiry cannot
02:39:19 it first declares that an inquiry cannot rule on and has no power to determine any persons civil or criminal liability and then it adds the following subsection but an inquiry panel is not
02:39:33 subsection but an inquiry panel is not to be inhibited in the discharge of its functions by any likelihood of liability being inferred from the facts that it determines or the recommendations that
02:39:44 determines or the recommendations that it makes from that we take that just because the inquiry is not a trial does not mean that matters of law are irrelevant to the justice
02:39:55 irrelevant to the justice it delivers importantly for phase one if there are breaches of public law and regulatory duties that are relevant to
02:40:06 regulatory duties that are relevant to the terms of reference then the inquiry must declare nothing in Section two indicates otherwise in fact it would frustrate the public interest not to do
02:40:17 frustrate the public interest not to do so because Parliament and others need to know where the causative conduct act and omissions was compatible with existing law and policy or not we have provided
02:40:33 law and policy or not we have provided you with the relevant tests for causation and the flexible standard of proof that operates in this investigatory context but based on that legal framework for these proceedings
02:40:45 legal framework for these proceedings can I make clear at the outset that our overarching submission is that the inquiries are positing a position to say now that multiple and fundamental breaches of legal duty contributed to
02:40:58 breaches of legal duty contributed to this disaster and that all of these deaths were preventable our submissions on the proposed findings to set out in
02:41:09 on the proposed findings to set out in detail at the end of the relevant sections of the G for written submissions in short we say that the inquiry can and should say now first
02:41:21 inquiry can and should say now first the patent failure to comply with building regulations materially contributed to all the deaths second the
02:41:33 contributed to all the deaths second the London Fire Brigade unreasonably failed to take steps that offered a realistic prospect of preventing these deaths it breached its policies and legal duties
02:41:45 breached its policies and legal duties under the Fire and Rescue Services Act and Human Rights Act in failing to plan or train for the foreseeable vent of a fire of this nature it should also have
02:41:59 fire of this nature it should also have pursued immediate fully evacuation on the night once it was clear that compartment ation of the building had so comprehensively failed third the
02:42:12 comprehensively failed third the emergency response of the category 1 responders fell short of the joint operation requirements of the civil contingencies Act 2004 now miss bar wise
02:42:26 contingencies Act 2004 now miss bar wise has just dealt with the building let me now outline the position on the emergency response the evidence that the lfb failed to adequately train and plan
02:42:41 lfb failed to adequately train and plan for a fire like that one at Grenfell tower is overwhelming on paper its policies and executive statements embrace the need to keep pace with
02:42:52 embrace the need to keep pace with common construction methods and the risks they pose including departing from stay-put advice and implementing evacuation when compartment Asian fails
02:43:03 evacuation when compartment Asian fails there was national guidance known as generic risk assessment 3.2 and the London policy number 633 and mr. Weatherbee Queen's cancer who follows on
02:43:15 Weatherbee Queen's cancer who follows on from me is going to deal with the background and content of these two policies including what we all say that there was a terrible gulf between paper
02:43:27 there was a terrible gulf between paper and practice what can undoubtedly be complete
02:43:33 complete by 2017 is that the lfp was aware of the prospect of a high-rise fire involving breach of compartment ation as a risk to
02:43:44 breach of compartment ation as a risk to life to be prepared for including specifically as a result of flammable facades the inquiry now knows very well
02:43:55 facades the inquiry now knows very well the signposts on the way the LF B's response to the Latin or House coroner in 2013 said it would prepare for fires that behaved inconsistently with the
02:44:06 that behaved inconsistently with the compartment ation principle develop comprehensive contingency plans for when it did and review inspection regimes and information gathering to identify risks before they arose the two big policies
02:44:20 before they arose the two big policies that I just mentioned were updated in 2015 a training package on at-risk buildings was produced to educate on cladding fire between the summer and
02:44:32 cladding fire between the summer and autumn of 2016 and our bkc with other councils across London were specifically warned by the lfb in a letter of April
02:44:43 warned by the lfb in a letter of April 2017 that cladding panels could be in breach of building regulations the state of corporate knowledge gives rise we say
02:44:54 of corporate knowledge gives rise we say to five conclusions from the phase one evidence that are inescapable and which various council will follow on to address you about first
02:45:06 address you about first this knowledge had not filtered down to station level through basic update or even operational training no phase one
02:45:17 even operational training no phase one firefighter witness could record being specifically trained about the risks of external planning fires the revision of a state policy or what to do in the event of a failure of compartment ation
02:45:28 event of a failure of compartment ation in a high-rise fire building second despite acknowledging the need for partial or full evacuation of a high-rise building the inquiry has
02:45:40 high-rise building the inquiry has received no evidence of any doctrine or training on this and no witness was able to give any operate insight into how to achieve it beyond unplanned door-to-door deployments as
02:45:53 unplanned door-to-door deployments as the need arose third the fast firefighting respondents gave evidence that demonstrated a
02:46:04 gave evidence that demonstrated a drastic failure to appreciate the breach of compartment ation occurring before their eyes they failed to comprehend that immediate evacuation was the only
02:46:17 that immediate evacuation was the only option and the entire and the entire building failure was inevitable fourth certain senior personnel including the incident commanders who arrived before 2
02:46:28 incident commanders who arrived before 2 a.m.
02:46:29 a.m. continued to miss characterize the nature of the fire despite the obvious risk of mass fatality and fear and I know that mr. Steen and mr. Mansfield
02:46:40 know that mr. Steen and mr. Mansfield will look at this closely before the fire notwithstanding the obligations under Section 7 to D and the various policies Grenfell tower was a
02:46:52 policies Grenfell tower was a chronically under assessed building the evidence of commissioner cotton in response to these manners matters
02:47:04 response to these manners matters brought her and her organization into disrepute everyone who has followed this inquiry will recall the woefully
02:47:15 inquiry will recall the woefully ill-judged and defensive statements that she wouldn't develop a training package for the space shuttle to land on the shard and that she wouldn't change anything about what her firefighters did
02:47:29 anything about what her firefighters did on that night not only were those comments insulting to the BSR but they were irresponsible they send a wholly
02:47:40 were irresponsible they send a wholly negative message about the LF beasts capacity as an organization to acknowledge its shortcomings and to make any real change in the future cladding
02:47:53 any real change in the future cladding fires are rare but notorious because they bear the highest prosper of catastrophe in a high-rise building on that basis the claim should have been
02:48:06 on that basis the claim should have been planned for but we're not this is also no time to patronize either the organization by consoling it that there
02:48:17 organization by consoling it that there were firefighters who acted heroically all the BS are by continuously reminding them that that was the cash as one of our bereaved clients has pressed upon us
02:48:30 our bereaved clients has pressed upon us succinctly what my family needed was not heroes but well-trained professionals well keep working to a well structured plan ultimately this is an issue of
02:48:46 plan ultimately this is an issue of institutional culture if the LF B is serious about making change then it needs to learn from its errors on the night of this fire its failure to do so
02:48:57 night of this fire its failure to do so is damning at the moment its leadership remains in denial if the phase one report does not disabuse them of that who will the inquiry can and should
02:49:09 who will the inquiry can and should therefore make findings and recommendations that identify the way in which the lfb breached its own policies and failed to discharge its legal duties of training resourcing and risk
02:49:21 of training resourcing and risk assessment without proper training or practice watch manager Dowden and others were therefore left to approach the fire
02:49:34 were therefore left to approach the fire based solely on past experience and that doomed them to error when faced with the unfamiliar they could not conceive of a
02:49:45 unfamiliar they could not conceive of a fire that breached the compartment ation of the building in such a horrendous way and they were blind to the obvious need for systemic evacuation that is why we described their operational failures as
02:49:57 described their operational failures as more institutional than personal but simply the evidence shows that this was a devastating episode of looking without seeing and hearing without listening as
02:50:11 seeing and hearing without listening as to looking without seeing Dowden was unable to register the obvious implications of breach of compartment ation across the building however his actions indicate more than
02:50:23 however his actions indicate more than he was ultimately willing or able to concede in evidence you do not start to deploy a covering jet and order the more
02:50:34 deploy a covering jet and order the more aggressive hydraulic pump all before 1:13 unless you know you are fighting an external fire of substance his movements
02:50:45 external fire of substance his movements to pump six before 114 and pumps 8 at 119 say the same by 126 he made pumps 10 and at 128 he made pumps 15 requested
02:50:58 and at 128 he made pumps 15 requested aerial x 2 and declared persons reported he did this because the fire was in his own words to the peer review halfway up
02:51:10 own words to the peer review halfway up the building and now getting into flats this was as early as 128 what he saw and what he did reflected an obvious breach
02:51:22 what he did reflected an obvious breach of compartment ation this was not a sector fire yet none of this translated into the full evacuation that was
02:51:33 into the full evacuation that was required as to hearing without listening watchmen is a doubt and was quickly informed that the smoke and fire had spread internally across the buildings at flaws 5 to 7 and then we say
02:51:46 at flaws 5 to 7 and then we say importantly on to floor 16 yet very little of this registered this was absolutely a situation where audio and visual information could be overwhelming
02:51:58 visual information could be overwhelming but that is why individual human judgment and rules of thumb alone cannot command major fires Dowden had no assistance from doctrine training or
02:52:10 assistance from doctrine training or experience to guide him to process the information that was so overwhelming what he needed to do was evacuate instead the only available conceptual
02:52:22 instead the only available conceptual anchor that he could resort to was the concert
02:52:25 concert of fire survival guidance and that proved to be fatally unhelpful it meant individual deployments to rescue particular occupants as the need arose
02:52:38 particular occupants as the need arose rather than a strategy to just get everybody out the experts confirm what the BSR witnesses made clear that before
02:52:50 the BSR witnesses made clear that before two o'clock the means of exiting the building still allowed people to get out as a matter of fact the sterols remain tolerably fear smoke before 1:30 and
02:53:01 tolerably fear smoke before 1:30 and indeed for some time thereafter even when most lobbies were filling up with dense smoke the staircase remained viable for 31 people to escape from 131
02:53:13 viable for 31 people to escape from 131 to 147 they followed the hundred and ten people who had escaped before that Professor purser calculated that simultaneous entry into the scare case
02:53:25 simultaneous entry into the scare case of the full cohort of 293 people across 23 stories could have resulted in evacuation within seven minutes the
02:53:36 evacuation within seven minutes the skeptics on this needs you particularly consider the evidence of petrol deliverer and her partner descending from the 20th floor at 142 and passing
02:53:47 from the 20th floor at 142 and passing multiple firefighters in equipment on the way just as they should consider the case of Branislav lukkage carrying clarita Gaffney over his shoulder
02:53:59 clarita Gaffney over his shoulder followed by his flat mat flatmates as they came down from the 11th floor at 147 the evidence points to what is no
02:54:10 147 the evidence points to what is no more than common sense from 115 the instant command ought to have confronted the clear dangers to occupants if they were to remain in the building before 1:30 it ought to have been obvious that
02:54:23 1:30 it ought to have been obvious that this fire was going to jeopardize its entire occupancy on this dr. Lane has agreed evacuations should then have been instigated by sending firefighters to
02:54:34 instigated by sending firefighters to the top of the building and immediately changing the control room advice loud hailers could have been used in the stairwell the intercom system could have
02:54:46 stairwell the intercom system could have at least been used to wake some people up mr. Weatherbee is going to develop this matter but let me make your point abundantly clear that hasn't perhaps had the attention that it should have had to
02:54:57 the attention that it should have had to date the ensuring evacuation would not have involved a crowd of strangers in a public place but neighbors and families
02:55:08 public place but neighbors and families navigating the stairs of their own home even after two o'clock there was never a point when it was impossible to descend
02:55:20 point when it was impossible to descend without breathing apparatus every dealing depended therefore on maintaining and optimizing the staircase and coordinated ba deployments the
02:55:32 and coordinated ba deployments the failure of the bridgehead throughout the night was that it Matt eclis stuck to an ad hoc rescue strategy and never contemplated facilitating escape in a
02:55:44 contemplated facilitating escape in a systematic way other counts so who follow will look at the markedly questionable results achieved by the DA
02:55:55 questionable results achieved by the DA deployments from the bridgehead that night regardless of the effort that was put in we summarized this subject under five points first
02:56:06 five points first the bridgehead never evacuated residents in watch managerial keeps language it tried to flood the building to undertake multiple rescues this is individual
02:56:20 multiple rescues this is individual rescues from individual flats in response to individual requests for assistance in doing that it pursued a strategy that could not work there was never going to be time to evacuate the
02:56:32 never going to be time to evacuate the entire building by this means it involved too many flats and too many diet diversions residents who had been told to stay put and await firefighting assistance were left without any realistic prospect of being reached
02:56:45 realistic prospect of being reached eventually opportunity to access them was
02:56:50 was second that breach head was starved of timely information to take powerful examples of delay from among our clients
02:57:01 examples of delay from among our clients Mary ml guar E and Naomi Lee both called the control room at 1:30 to tell them there was a fire on the 22nd floor the
02:57:12 there was a fire on the 22nd floor the 22nd floor was immediately mentioned in a radio service request at 1:30 to the 23rd floor where Miriam and her mother Isla had now moved to was communicated
02:57:23 Isla had now moved to was communicated in the telephone conversation between operation manager Norman and one of the Cu staff at 135 the first known FSG list at the fire ground contained flat one
02:57:37 at the fire ground contained flat one nine five on the 22nd floor and flats 205 and 204 on the 23rd floor based on its detail we can time that list being written after 147 yet despite the red
02:57:52 written after 147 yet despite the red flagging of these flats and floors there was no FSG appointments to floor 23 until 208 and then no but no further
02:58:03 23 until 208 and then no but no further deployments into 224 and 251 even worse for a fire that was reported to have broken out on the 22nd floor as early as
02:58:14 broken out on the 22nd floor as early as 1:30 no one was deployed to the 22nd floor until 303 no firefighter ever reached the 23rd floor and although
02:58:25 reached the 23rd floor and although firefighter Roberts made it up to the 22nd he searched neither the lobby nor the flats so reports of a fire at 1:30 no response at all before 208 and
02:58:39 no response at all before 208 and thereafter no systematic approach the fire on those two floors claimed the lives of 36 people half the number of
02:58:50 lives of 36 people half the number of all the deceased in that fire third scared were scared resources to respond to FSG calls were wasted
02:59:02 respond to FSG calls were wasted two examples illustrate the point there are several but consider the paddington fruit in the first specialist EDB a rescue unit to attend the sing sent on a
02:59:16 rescue unit to attend the sing sent on a hopeless mission to the roof at 156 to sling ropes over the top of it to try and spray water down the side they saved for duma armored life but
02:59:29 they saved for duma armored life but this was a specialist team able to operate at the highest floors and had they been deployed in a coordinated relay without the extra rate of unnecessary equipment it must be likely that they could have done more to save
02:59:42 that they could have done more to save others most inexplicable of all the delay in deploying the available extended duration breathing apparatus
02:59:53 extended duration breathing apparatus crews the statements of the EDB a crew members described being held outside to get bottles of water and general supplies of hoses and breaking-in
03:00:05 supplies of hoses and breaking-in devices the sobering schedules available to the inquiry showed that the delay in deploying these desperately needed crews into the tower exceeded between one and
03:00:16 into the tower exceeded between one and one and a half hours forth no one questioned the individual rescue approach the majority of evacuations were either without any assistance or only partially assistant assisted
03:00:28 only partially assistant assisted towards the bottom of the stairs the number of successful assisted evacuations directly from a flat or lobby throughout the night was few indeed and on the most generous
03:00:41 indeed and on the most generous interpretation our estimate comes to 12 flats and all lobbies involving 28 people the bridgehead did not learn from the low return and
03:00:54 did not learn from the low return and ineffectiveness of its own strategy which leads to the fifth point that the bridgehead also did not learn from successes for instance fewer deployments but with the benefit of spare ba masks
03:01:07 but with the benefit of spare ba masks and sets for the use by residents might have reduced to Podesta like the evacuation of Sharon Lacy and daughter equally no one apparently
03:01:18 daughter equally no one apparently registered the implications of significant numbers of self evacuations after 3 o'clock in the morning these survivors were not just young and fit adults mr. and mrs. McGee's came down
03:01:32 adults mr. and mrs. McGee's came down from the 16th floor at 347 they were not young and in the latter case suffer from mobility issues and chance escaped with her 55 year old mother and 62 year old
03:01:44 her 55 year old mother and 62 year old art from the 10th floor at 4:21 child was lost on the staircase in the worst possible circumstances and an unborn
03:01:56 possible circumstances and an unborn child died but 9 children aged 3 to 12 years old escaped from grenfell tower between 3 and 4 and many of them had to
03:02:07 between 3 and 4 and many of them had to come down unaided finally there is no evidence to indicate that the gold born system introduced after about 3:20 made
03:02:20 system introduced after about 3:20 made things particularly better under the direction of group managers Golborne welsh a substantial number of edpa crews were wastefully diverted to the lower floors instead of to the FSG cause on
03:02:32 floors instead of to the FSG cause on high applause these were crucial missed opportunities notably including for the remaining residents on floor 14 I turned
03:02:43 remaining residents on floor 14 I turned to overall command of the fire ground our headline point is that for much of the night the incident had hierarchy but it lacked proper command first that one
03:02:58 it lacked proper command first that one should never have been left there that long he knew it others knew it DCO Lachlan couldn't understand it second all three of the incoming commanders
03:03:09 all three of the incoming commanders before 2 a.m. inexplicably failed to appreciate or discover that the fire had broken into individual flats across the building the inquiry has evidence from officers bill
03:03:22 inquiry has evidence from officers bill Mulholland Harrison and leaver that this was completely of as it was to a number of rank-and-file firefighters and indeed police officers
03:03:33 firefighters and indeed police officers third the lost first hour was compounded by the drifting decision-making in the second our incident command still did not establish the extent to which
03:03:44 not establish the extent to which individual flats were in jeopardy the failures of the bridgehead were not appreciated a major incident was called without coordinating with the other emergency services still no one picked
03:03:56 emergency services still no one picked up the phone to brigade command fourth just after 2:00 a.m. a watch manager mr. Harrison intervened at the
03:04:07 manager mr. Harrison intervened at the door to the command unit to press for a revision of post a prett advice Andrew rate and related measures to aid evacuation he referred to the matter in his notes the next day it is highly
03:04:19 his notes the next day it is highly likely we submit having seen him give evidence that this man did intervene at the door of a crowded tents command unit but was not heard we say that this
03:04:32 but was not heard we say that this intervention and the officers reaction were symptomatic of something bigger and it is a shame that he's not seen that way by the LF being it draws parallels
03:04:43 way by the LF being it draws parallels with other sectors that have had to address the difficulty of the junior ranks pointing matters out to command when it really is a matter of life and
03:04:55 when it really is a matter of life and death I'm talking about the experienced nurse in the operating theater the navigator in the jet plane and the junior officer and supportin on the battlefield there a specific criticism
03:05:10 battlefield there a specific criticism of Assistant Commissioner Rove is that he found no means to influence the drift of command once he was aware of the magnitude of the fire but prior to his arrival from the picture of the fire
03:05:22 arrival from the picture of the fire sent by station manager cook at 1:43 he understood that 100% of the building was alight and that this was an undeclared major incident but Roe had no strategic
03:05:33 major incident but Roe had no strategic input before it was far too late that said neither did his assumption of command resulting a change of doom strategy at the bridgehead or improved communications with the control
03:05:45 improved communications with the control room now the failure of incident command to brief the control room undoubtedly
03:05:56 to brief the control room undoubtedly impacted on the quality of advice given by its operators on the night however the BS are viewed the control room as bearing its own very significant
03:06:09 bearing its own very significant failures during the lack nor house fire see arrows have assumed wrongly that compartment ation would not fail and
03:06:20 compartment ation would not fail and that the fire crews would reach callers quickly an adequate post nap no response needed to one identify compartment ation
03:06:32 needed to one identify compartment ation failure as a paradigm shifting event in a high-rise fire to speedily revoked stay perked advise 3 maximize
03:06:43 stay perked advise 3 maximize intelligence to aid immediate evacuation and 4 operate effectively at overflow call capacity none of this happened for
03:06:55 call capacity none of this happened for the callers from grim felt our first operators could again not conceive of breach of compartment ation within a tower block instead they repeatedly told
03:07:07 tower block instead they repeatedly told callers that the fire was on the fourth floor or on another lower floor even when the caller was telling them that it was not operators reassured people that they were safest staying in their
03:07:18 they were safest staying in their property despite very early reports of smoke and fire spread across the building and they continuously told people that the firefighters were on their way when there was no way of knowing that this was the case second
03:07:31 knowing that this was the case second there was no shared interpretation of what it meant with Vice callers to remain in their properties on the grounds that they were in the words of policy 790 not affected by fire heat or
03:07:47 policy 790 not affected by fire heat or smoke some operators fought the word effect
03:07:52 effect required there to be fire in the flat other sports smoke was enough a fire outside or next door counted for some operators but not for others there as
03:08:08 operators but not for others there as with the firefighters these operators were denied proper training and bluntly were therefore not qualified to do the job they needed to do on the night experience of giving any type of FSG
03:08:22 experience of giving any type of FSG advice was rare no one had practice or even contemplated the role of counseling escape by telephone during a high-rise mass evacuation when the time came to
03:08:34 mass evacuation when the time came to give such advice the operators had to improvise in what was essentially an alien discipline consequent problems included callers being offered the
03:08:45 included callers being offered the choice whether to stay or go when there was none being told they needed to leave but simultaneously advised that efforts were still being made to get to them being there as unable to say in the
03:08:58 being there as unable to say in the plainest possible terms that pleas for helicopters and high ladders were never going to be met and failing to carry out callbacks to inform residents who had
03:09:10 callbacks to inform residents who had been told to stay put in circumstances where the strategy had changed and they now needed to get out despite provision in national policy GRA
03:09:23 despite provision in national policy GRA 3.2 neither lfb policy or training required callers to be asked about mobility or disability issues there was also no training on how to build empathy
03:09:35 also no training on how to build empathy and Trust with people from different cultural religious and language backgrounds there remains significant concern that the revocation of the
03:09:46 concern that the revocation of the stay-put advice was not relatedly to some residents for whom English was not a first language and more generally that some operators failed to
03:09:57 that some operators failed to communicative ly with such residents and terminated calls with them rather than staying on the line until there is organized access to the tapes of the course we will not know
03:10:10 tapes of the course we will not know until then we do say as a matter of law section 1 4 9 of the Equality Act 2010
03:10:23 section 1 4 9 of the Equality Act 2010 required the proactive consideration by the lfb of how to remove or minimize disadvantage connected to protected characteristics including race and
03:10:34 characteristics including race and disability we have seen no evidence of the formal discharge of that Duty yet and Livan requiring must get to the bottom of this issue in phase 2 in relation to the control-room
03:10:45 relation to the control-room just as it must consider the compliance of others for the resident school should have acted as an early warning of building failure but the control room and the incident command failed to grasp
03:10:57 and the incident command failed to grasp this at 124 cro daddy heard a female caller who it can be established to be damiana Lewis on the 12th floor shouting for help that the fire was in her
03:11:09 for help that the fire was in her kitchen and that she could not breathe at 125 om Norman received a report from Dennis Murphy describing logging on the for smoke logging on the 14th floor lobby that was preventing him from
03:11:22 lobby that was preventing him from leaving she told him that if leaving meant using the stairwells which she asserted wrongly were filled with smoke he was better off staying where he was at 1:26
03:11:33 at 1:26 cassia de braska from flat 95 also on the 12th floor informed cro cop Fox that her neighbor had told her there was a fire in her kitchen and that smoke was
03:11:45 fire in her kitchen and that smoke was entering her own flat through the main door when told that the fire was only in flat 16 she and fatica Lee corrected the CRO stating that the fire had already reached her floor there was then a
03:11:58 reached her floor there was then a series of calls at 1:30 that indicated that the fire had internally reached the top floors of the building at precisely 1:30 cro daddy was informed by Miriam
03:12:11 1:30 cro daddy was informed by Miriam algerie of the fire in her kitchen on the 22nd floor she had fled to the 23rd she connected she corrected his assurance that the fire was on the fifth
03:12:22 assurance that the fire was on the fifth floor and made it plain that smoke was present in her new location at the very top of the tower at 1:30 Oh - Helen gave romesco from the 21st floor told om
03:12:34 romesco from the 21st floor told om Norman that there was fire in the floor below and that smoke was coming up into her flat at 1:30 Oh 8 CRO Russell began the call with Jessica Barnard Ramirez
03:12:47 the call with Jessica Barnard Ramirez situated on the top floor who immediately told her that there was a fire in the kitchen and who smoke was coming through the floor also at 1:30 Oh 8 CEO Fox was informed by Antony dissin
03:13:00 8 CEO Fox was informed by Antony dissin that the conditions on the 22nd floor were terrible and he could not see his hand in front of him at 1:30 38 Niomi Lee who had first identified smoke on
03:13:13 Lee who had first identified smoke on the 22nd floor at 1:21 was now able to inform CRR guts that there was a fire in her neighbors kitchen and they could smoke smell smoke she was told obviously
03:13:25 smoke smell smoke she was told obviously I can't really advise you but I'll let the firemen know you're there thereafter Burak huffed him a child calling from the top floor held CRO Houston at 1:32
03:13:38 the top floor held CRO Houston at 1:32 that there were lots of smoke in the flat and the window was burning up during the call an adult could be heard saying oh my god the fire is coming through at 1:33 a caller from the 11th
03:13:50 through at 1:33 a caller from the 11th floor could be heard shouting please please
03:13:53 please the fire is in my flat the fire is in my flat we say the residents were the source of situational awareness the
03:14:05 source of situational awareness the incident command so sorely lacked and did itself not provide yet the first contact that om Norman had with the command unit at 1:35 past on some detail
03:14:18 command unit at 1:35 past on some detail but did so only as one dimensional FSG caused flats and doors requiring individual search and response what was needed was a
03:14:31 response what was needed was a high-level intervention between control and incident command to identify and dramatically act upon the clear overall picture of building failure and that did
03:14:42 picture of building failure and that did not occur a final point for the calls is that although this was a fire in London the control room response needed to be
03:14:54 the control room response needed to be nationwide despite having resources available naan l FB control rooms lacked intelligence regarding the situation at the fire ground and only belatedly
03:15:06 the fire ground and only belatedly learnt about the change to the statehood advice as of June 2017 every brigade knew of the risk of overflow calls and the need for body control rooms but
03:15:17 the need for body control rooms but there was no protocols or joint policies in place either between the brigades or with beating a simple conclusion follows
03:15:28 with beating a simple conclusion follows from all these failures these shortcomings in the control room service undeniably contributed to people dying and will continue to do so in similar
03:15:41 and will continue to do so in similar circumstances until the system acquires the training and technical capacity to offer inform strategic advice to mass volume callers including the capacity to
03:15:56 volume callers including the capacity to recontact them through multimedia when the advice changes there is then a last feature of the response on the night to
03:16:07 feature of the response on the night to address under the civil contingencies Act 2004 various so-called category run respondents are required to plan for emergencies and work together when they
03:16:18 emergencies and work together when they arise our basic observation which we develop in writing is that you cannot have major incidents separately declared by each service at different times
03:16:30 by each service at different times without the knowledge of the others declaration with no coordination on critical changes of strategy especially here the changed the statement advice sensibly call it a joint operation of
03:16:44 sensibly call it a joint operation of some importance in this respect was the role of the police in giving FSG guidance and passing on to lfb information from members of the public regarding their family and friends still
03:16:55 regarding their family and friends still in the turn that they're having said that I want to address the role of our bkc and therefore by extension the TMA our bkc is the local authority
03:17:06 our bkc is the local authority fundamentally breached its duty under regulation 11 to be of the regulations for the 2004 act it failed to provide reasonably obtainable information to the
03:17:18 reasonably obtainable information to the LF bill in relation to residents plans and known deficiencies in the fire prevention mechanisms of the building of all these matters on all these matters
03:17:29 all these matters on all these matters it delegated to the TMO which was not subject to clear equivalent statutory duties under the 2004 act or its regulations the management contract is
03:17:42 regulations the management contract is silent on the point and we do not know yet what the Understanding between the two organizations was if there was anything on that for the time being I
03:17:53 anything on that for the time being I can make no further Arcata our concessions but there clearly is something to be concerned about when the evidence for the night shows that the
03:18:04 evidence for the night shows that the local authority was looking to the TMO and the TMO was looking to the local authority in other words there was an operational gap potentially facilitated
03:18:15 operational gap potentially facilitated by the current state of our social housing law for the TMO officers to say that their own emergency plan was irrelevant to grin to the grenfell fire
03:18:27 irrelevant to grin to the grenfell fire because of the scale of the emergency meant that there was no plan at all the teemo's plan in any event was
03:18:38 the teemo's plan in any event was redundant it dated back 15 years did not reflect the refurbishment and assumed 8 to 12 bun durable residence without meaningful definition or detail the senior management of the TMO say that as
03:18:50 senior management of the TMO say that as of the night of the fire they had no knowledge of the wholesale defects in fire safety if that is correct
03:18:59 correct their evidence to date can only mean that they did not know about the statutory notice sent by the fire Authority in November 2016 identifying defects in self closing
03:19:10 identifying defects in self closing doors that they did not know of or appreciate the significance of the letter sent to our bkc by the LF be in April 2017 warning about
03:19:22 by the LF be in April 2017 warning about cladding not built in accordance with building regulations and it must also mean that they had no knowledge of the litany of patent defects identified by the inquiries experts some of which from
03:19:35 the inquiries experts some of which from a non expert perspective were posited and pointed out by residents before the fire I would these witnesses were not telling the truth about the extent of
03:19:47 telling the truth about the extent of their knowledge or they led a dysfunctional organization incapable of insuring fire safety or of course both the BS are look forward to the inquiry
03:19:59 the BS are look forward to the inquiry investigating and making conclusive findings on this in phase two finally the residence the evidence of the BS are both all and written was significant in
03:20:13 both all and written was significant in multiple respects first it commemorated the loss of Grenfell tower and its community just as the opening hearings commemorated the loss of its people second it provided critical detail and
03:20:26 second it provided critical detail and insight into the problems with the building the spread of the fire and the response to it prior to the fire residents identified many of the causes of the disaster to come doors that did
03:20:39 of the disaster to come doors that did not close windows and cladding with gaps a note a smoke ventilation system that likely did not ventilate and significant shortcomings in preparing residents to respond to a fire and if necessary self
03:20:52 respond to a fire and if necessary self evacuate third the near death experience of survivors provides a further Human Rights context they to require an
03:21:03 Rights context they to require an investigation into truth that will respect their hue and dignity and restore their sense of security but it doesn't stop there by courageously giving evidence oral and
03:21:15 courageously giving evidence oral and written regarding their harrowing experiences the survivors have added vastly to the understanding of human behavior in fire as well as acting as the informed eyes and ears of the fires
03:21:27 the informed eyes and ears of the fires progress they're invaluable testimony must educate further thinking on design evacuation search and rescue disability access and so much more if one looks
03:21:41 access and so much more if one looks then to those who died we should mention first that the inquiry has stated that it will not deal with the details of individual devs today but those special hearings will take place in the new year
03:21:52 hearings will take place in the new year when we do get to face two it will also be important to reflect on how and why and the implications of the fact that a very high proportion of black and
03:22:04 very high proportion of black and minority ethnic Londoners came to be housed together and died at groennfell Tower that figure of 90% of the deceased
03:22:15 Tower that figure of 90% of the deceased needs to be given its due regard it will also be necessary to investigate how so many people with disabilities rending that rendering them unable to
03:22:26 that rendering them unable to independently evacuate came to be housed on upper floors so we say that all of these deaths were preventable and by way
03:22:38 these deaths were preventable and by way of since it's a generic submission can we end by emphasizing four points first the events on floor 16 prior to 1:30 for shadowed the prospect
03:22:52 prior to 1:30 for shadowed the prospect of disaster by that time firefighters Hipple stern and O'Byrne on the landing were able to convey to the bridge head that a fourth floor kitchen fire now post a mortal danger twelve floors up
03:23:05 post a mortal danger twelve floors up acting on that information could and should have changed everything second the lift could not be controlled via our firefighters override switch
03:23:18 via our firefighters override switch and was not otherwise disabled to prevent it from being called by residents one person definitely but probably three died because of that lift alle Jairaj fre maja Bernardo to cou and
03:23:32 alle Jairaj fre maja Bernardo to cou and kahdijiha ha Luffy third the four deaths on floor 14 Dennis Murphy Muhammad Al Kigali Zainab Dean and Jeremiah Dean
03:23:46 Kigali Zainab Dean and Jeremiah Dean involved a catalogue of failures for people were left to die who had been reached by firefighters three times the fact that eight rages and residents had
03:23:57 fact that eight rages and residents had been congregated into one room was written into multiple places but the teams that went up on the final occasion were not briefed that they needed to rescue eight people in breach of policy
03:24:08 rescue eight people in breach of policy the flat was not properly searched for residents were led we will return at the subsequent hearing to outline why we say that firefighter herrera's account is
03:24:19 that firefighter herrera's account is untrue and in any event unreasonable but then to further EDB a teams were deployed to 14 with slips in their hands only to be told by officers to divert to
03:24:31 only to be told by officers to divert to firefighter duties on the lower floors taking all these factors together floor 14 stands as a paradigm of preventable death for the higher floors were never a
03:24:44 death for the higher floors were never a lost cause the accounts of the late escapes both soul and assisted indicate that death was preventable for some time which is why the continuing delays and
03:24:55 which is why the continuing delays and confusion over the stay put part advice even after its change at some point between 235 and onwards are matters of grave concern to the bereaved families
03:25:08 grave concern to the bereaved families of those higher floors finally the fate of those higher floors is bound up with migration of people from Lower Falls several people went onto the staircase just before 1:30 when safe evacuation
03:25:20 just before 1:30 when safe evacuation was entirely possible but ultimately went upstairs we cannot stress enough that there was enough firefighters in the building to honor call unequivocally
03:25:31 the building to honor call unequivocally them down call-out prompt pursue and usher them down that is what was available at that time our conclusion
03:25:42 available at that time our conclusion then from six months of hearings and eighteen months of your work the interim report of this inquiry needs to contain
03:25:54 report of this inquiry needs to contain a clear finding that none of these deaths from the fire at Grenfell tower were the product of accident they occurred because the building has
03:26:05 occurred because the building has refurbished was made into a deathtrap the inquiry can work out in due course the hierarchy of causation as well as
03:26:17 the hierarchy of causation as well as other contribution but the way the building was refurbished including its patent non-compliance with the building regulations cost lives and all of that
03:26:29 regulations cost lives and all of that can and should be said in the face of one report of course if that is what you have discovered then I am bound to
03:26:41 have discovered then I am bound to observe but just one other reason why this inquiry is so important going forward to phase two is that it is in investigating the potential unlawful
03:26:52 investigating the potential unlawful killing of seventy two people additionally the inquiry should find that the lfb failed to take steps that could have changed matters in the way that I have summarized and my colleagues
03:27:04 that I have summarized and my colleagues are going to now develop finally it is important to record the facts and explain the reasons for the non-compliance with the civil contingencies act the great value of
03:27:16 contingencies act the great value of this process is that it is a once-in-a-generation opportunity to consider how to better prepare for urban disasters but in order for that to happen the various agencies especially
03:27:29 happen the various agencies especially the NFB have to confront the truth of how they could have done better on the night these findings are required to fulfill the inquiry statutory duties
03:27:41 fulfill the inquiry statutory duties they are inescapable on the evidence and there is an over roaming societal interest in publicly declaring them as soon as possible sir as to those we act for only time may
03:27:54 as to those we act for only time may heal what you have heard about but people are here today because they want justice they look to your first report as the beginnings of that endeavor thank
03:28:09 as the beginnings of that endeavor thank you thank you very much mr. Friedman well that's a point at which I think we should break for some lunch we'll stop now and come back at 2:15 please