Closing statements from bereaved, survivors and residents' legal teams (G3) addressing fundamental building failures, London Fire Brigade's emergency response, lack of evacuation planning, FSG process failures, and communications breakdown.
00:10:48 well now it's time for me to invite mr. Weatherbee to speak on behalf of what we call the g3 mr. Webber thank you very much I'm going to address you on three areas if I may
00:11:00 you on three areas if I may firstly some general comments on the disaster and the high level general conclusions that the face 1 expert evidence unquestionably points towards in terms of fundamental non-compliance
00:11:12 in terms of fundamental non-compliance with building regulations and the reckless disregard for human lives that is represented by the multiple failures in design materials fabrication build
00:11:24 in design materials fabrication build oversight and the refurbishment and the maintenance the building itself secondly I'll pick the baton up from Danny Friedman regarding the London Fire Brigade in candor and the comments of
00:11:36 Brigade in candor and the comments of Danny cotton in particular and the nature and prevalence of an institutional defensiveness more generally and how we say the inquiry should deal with it and thirdly and most substantially I'll turn to the two main
00:11:49 substantially I'll turn to the two main themes regarding the lfp emergency response the lack of any contingency planning in particular the failure to have all to improvise a plan B to evacuate the tower and the failure of
00:12:01 evacuate the tower and the failure of the FSG process actually on the fire ground itself these were in our submission the key systemic failures on the part of the LFP which almost certainly led to a greater loss of life
00:12:12 certainly led to a greater loss of life in doing so I'll endeavor to remain within my one hour to stray slightly over it as has already been stated that
00:12:24 over it as has already been stated that the grenfell fire was certainly a preventable calamity designed manufactured and built not accidental we join with others in urging you to make that clear in the interim report there
00:12:38 that clear in the interim report there was no natural course no act of God no matter how many times certain witnesses and core participants repeat terms like unprecedented and unique which we've heard this morning or perfect storm it's
00:12:52 heard this morning or perfect storm it's impossible to get away from the catalog of failures that the inquiry experts in particular have already spoken to I'm not going to repeat that evidence Stephanie bar wise has already addressed
00:13:03 Stephanie bar wise has already addressed you comprehensively on that but a particular feature of the expert evidence is the fact that there is such a high degree of agreement between the various experts with only minor shades
00:13:14 various experts with only minor shades of difference also although there is some challenge to the phase one expert evidence in written closings by one or two the corporate CPS the areas of
00:13:25 two the corporate CPS the areas of challenge are relatively narrow and there does not appear to have been any provision of contrary expert opinion there's no doubt that would have been disclosed more generally the expert evidence provides a long list of
00:13:36 evidence provides a long list of failures gross failures not just the combustible cladding both outer rainscreen and insulation but the altered window positioned creating dangerous for it's packed with
00:13:47 dangerous for it's packed with combustible foam membranes and insulation uPVC windows surrounds polystyrene infill panels all highly combustible lack of cavity barriers
00:13:59 combustible lack of cavity barriers front doors about closers different from those tested for fire resistance the lack of firefighter lifts no plans for evacuating vulnerable residents and no mitigation of those risks just some of
00:14:11 mitigation of those risks just some of the obvious and gross deficiencies with the building and its management a building that no one forget with one staircase no sprinklers and no general alarm a building populated with many
00:14:23 alarm a building populated with many elderly people and children those with disabilities and mobility issues those particular features being well known to relevant public authorities such as the
00:14:34 relevant public authorities such as the owner and landlord rbk see in the TMO and also those who designed and under talked and signed off at the refurbishment and those who were supposed to regulate it and indeed the
00:14:46 supposed to regulate it and indeed the fire service for today's purposes let me pose a shorter list and I do it as a question on the evidence what parts of the refurbishment were done so anything
00:14:57 the refurbishment were done so anything approaching a reasonable fire safety standard which active or passive fire safety provisions were appropriate and functioning on the night that is a very short list
00:15:08 on the night that is a very short list if it's a list at all dr. Lane referred to fundamental non-compliance we'd be rb4 in her report we would take that
00:15:20 rb4 in her report we would take that opinion further and submit that such a catalogue of failure shows a reckless disregard for human life by those involved in the design and build of the refurbishment project those who
00:15:31 refurbishment project those who manufactured and marketed the products and those who learn to talk the works and those who fail to quality ashore and properly sign it off we'd also add and appoint will press in Phase two that
00:15:43 appoint will press in Phase two that while there was fundamental non-compliance with building regs and shocking disregard for the guidance in ADB no reasonable designer or procure in our submission would in any event see a
00:15:55 our submission would in any event see a DB as providing all the answers properly viewed it's a risk assessment tool a list of the considerations that should be brought into play in considering life safety not a blueprint for safe design
00:16:07 safety not a blueprint for safe design to view a DB otherwise is to ignore the complexity of modern cladding systems and the obvious known risks they posed well though they'll be much more work to do in Phase two you've commissioned and
00:16:20 do in Phase two you've commissioned and published called and heard considerable and detailed evidence about the comprehensive and gross non-compliance with any reasonable standard and we join with all of the other furry and
00:16:31 with all of the other furry and survivors and displaced residents teams in urging that you set out headline conclusions in the interim report so that phase two can focus on just where those gross failures were who's
00:16:44 those gross failures were who's accountable for them and why it was all allowed to happen a community turned into a warzone improper prosperous Kensington and Chelsea in a country in a position to
00:16:55 Chelsea in a country in a position to have high regulatory and health and safety standards the detail of the failures and who did what just one and why may be the subject of close consideration of emails and contracts
00:17:07 consideration of emails and contracts and technical drawings-- but the broad picture is clear for all to see they address you now many were even survivors the victims suffer severe psychological if of the night many lost family and
00:17:20 of the night many lost family and friends and all lost community many of my clients no doubt others - they're still to settle in new homes they're looking for answers 18 months has passed
00:17:34 looking for answers 18 months has passed no one has taken any responsibility for the disaster and that is a major open sore for the bereaved and the survivors all of the corporate and public authority institutions are big on
00:17:46 authority institutions are big on condolences and sympathy but as a generality repeated in the recent written closings they say in effect it was all a series of unfortunate and
00:17:57 was all a series of unfortunate and unforeseen events it was not their fault because their product was not used correctly it was for someone else to check the specification the build quality to sign the work off that the
00:18:10 quality to sign the work off that the regulations weren't clear so far the enquiry has only had a book of excuses I've made this point before but I need to repeat it
00:18:21 to repeat it the written closing arguments are more of the same our conic points at the insulation not the ACM they state the phase one expert evidence quote establishes that it was a confluence of
00:18:33 establishes that it was a confluence of unfortunate circumstances and not the mere presence of a CMP a which created the conditions for the Graham fall fire kingspan points at the configuration but
00:18:45 kingspan points at the configuration but since the far they've been marketing the same product for use on high-rise residential buildings Celotex say what amounts to nothing studio Ian Hartley's the clutters actually say nothing no
00:18:57 the clutters actually say nothing no closing at all will Poole say there's not enough evidence to find the fire started in their appliance rich visa Ryden say the fire must have escaped
00:19:08 Ryden say the fire must have escaped only through the open window not via the menu of combustible products that they arranged to be packed around the windows of the void or the voids phase - that will not be concerned so much with what
00:19:20 will not be concerned so much with what actually happened the fire and the dangerous state of the building on the night but why it was allowed who was responsible for the overarching failures of design procurement compliance build quality quality control
00:19:33 compliance build quality quality control sign-off lack of maintenance who's accountable for the particular aspects of the building failure so not much help from the corporate CPS on this so far or indeed public authorities either as I'll
00:19:46 indeed public authorities either as I'll come to in a minute candor mr. Friedman spent some time in the culture of the London Fire Brigade and the disappointing view of Danny cotton who
00:19:59 disappointing view of Danny cotton who concluded her evidence quote I wouldn't change anything we did on the night unquote I just want to pick that particular baton up and run with it a little further firstly though a very
00:20:11 little further firstly though a very important clarification and so important that I make no apology whatsoever for repetition lfb did not put manifestly dangerous cladding on Graham fall tower
00:20:22 dangerous cladding on Graham fall tower they didn't cause the fire I join with most others in recognizing the courage of the many firefighters who risks that risked their lives to save others and that isn't just a trite statement
00:20:35 that isn't just a trite statement although others raised a number of issues regarding the conduct of particular firefighters or the control room the context is that firefighters going into the term must have had images of collapsing buildings in their minds
00:20:47 of collapsing buildings in their minds and they went into conditions where they could not see anything because of the smoke and we've actually seen that on various videos during the course of the evidence a truly horrific fire ground
00:20:58 evidence a truly horrific fire ground scenario to borrow a phrase for insid alley at Varney from the level 15 I direct my comments at the suits and not
00:21:09 direct my comments at the suits and not the helmets where lfb correct in their opening indeed in their closing in effect to say there was little that they could have done other than try and put the fire out and rescue individuals are
00:21:22 the fire out and rescue individuals are they correct to say that valid criticisms are either two points of detail or from hindsight and we're impossible to foresee is it right that the introduction of smoke codes and a
00:21:34 the introduction of smoke codes and a few changes behind the scenes to some of that Paula these will suffice at some point undetermined in the future we say that's a very disappointing stance which not
00:21:45 a very disappointing stance which not only ignores the reality of the evidence that comes from an engrained culture of denial it's also dangerous because those who fail to learn the lessons of the past are going to repeat their failures
00:21:56 past are going to repeat their failures in the future in the face of a terrible tragedy the response appears to be that it's the duty of senior managers to defend the institution in the face of the fact rather than act with candor
00:22:07 the fact rather than act with candor accepting the stark reality of what the evidence shows did lfb learn the lessons from Lacan all why was the no evacuation contingency plan why did the FSG process
00:22:19 contingency plan why did the FSG process fail so badly on the night a culture of denial or institutional defensiveness not only prevents us all the victims and the wider public as well from learning
00:22:30 the wider public as well from learning what actually did and didn't happen not only does it make accountability more difficult to determine but it also may means that mistakes of the past will happen again and lives will be
00:22:41 happen again and lives will be endangered Danny Friedman spoke about the culture of the lfp I'm not going to repeat that submission but I want to widen it because it will continue to be
00:22:53 widen it because it will continue to be relevant to the other public authority in corporate CPS and this inquiry I've already demonstrated that by referring to the complete absence of anybody accepting either any wrongdoing or any
00:23:05 accepting either any wrongdoing or any failures to date this isn't some unique or novel problem it's well known well documented by a series of Inquiry reports and notorious cases that denial
00:23:17 reports and notorious cases that denial and defensiveness is the default position not the exception of many perhaps most institutions both public and private so robert francis rackin
00:23:28 and private so robert francis rackin recognized this as an endemic problem and his report into the mid staffs NHS foundation trust his recommendation led to a legal duty of candor being imposed
00:23:40 to a legal duty of candor being imposed on health care providers by the 2014 regulations February 2015 the Equality and Human Rights Commission Report preventing deaths in detention of
00:23:51 Report preventing deaths in detention of adults with mental health conditions recognized exactly the same problem in the deprivation of Liberty sector dr. Kirk ups March to 15 report in two
00:24:02 Kirk ups March to 15 report in two failures of the Morecambe Bay and HS trust picked up the same mantle again recognizing the need for a duty of candor specifically in the way that institutions prevented their evidence at
00:24:13 institutions prevented their evidence at inquests and in a recommendation indicated a specific need for regulation in that area July 4 to 15 the Harris review into the report of the
00:24:24 review into the report of the independent review into self inflicted deaths in custody of 18 to 24 year olds the theme again arose a specific mention of institutional defensiveness the
00:24:37 of institutional defensiveness the bishops report into Hillsborough which I'm sure you're familiar recognized repeatedly the problems of institutional lack of candor and promulgated the Charter for public authorities to sign
00:24:49 Charter for public authorities to sign to promise to act with integrity and candor that report was of course with respect to a process that took nearly 30 years to achieve a just out front
00:25:00 years to achieve a just out front incidentally whilst most people remember the role of the police at Hillsborough it's worth remembering that a substantial secondary issue in that disaster concerned the emergency response both by the police and the
00:25:11 response both by the police and the ambulance service the context of Grem field is of course very different but the parallels are there for all to see no one sought to criticize the individual police and ambulance staff
00:25:23 individual police and ambulance staff battling to save lives but the new Inc West jury concluded that the failures promptly to declare a major incident to establish command and control to coordinate income and communicate in
00:25:36 coordinate income and communicate in effect to follow long-established major incident principles delayed an effective response and contributed to the death toll the other parallel is that throughout the process the police and
00:25:48 throughout the process the police and the ambulance service flatly refused to accept that their commanding control failures that materially affected the emergency response institutional defensiveness that we say is being
00:25:59 defensiveness that we say is being repeated
00:26:00 repeated here by the other in these proceedings I'll be Casey have signed up to the bishops charter as indeed as the man but we're unaware of any other public
00:26:13 we're unaware of any other public authorities CP having done so or indeed private corporations promising to act within its spirit and although our bkc have publicly announced their commitment
00:26:24 have publicly announced their commitment to the Charter and indeed discussed adherence to it with us we make clear that we still await 18 months down the line anything approaching a full statement regarding their role in the
00:26:36 statement regarding their role in the disaster we make clear to them that candor must be demonstrated not announced it's not a public relations tool our bkc owner responsible person
00:26:48 tool our bkc owner responsible person responsible for the planning committee responsible for building control involved at all levels and they know many of the legal responsibilities stop with them they must have a lot to tell
00:27:01 with them they must have a lot to tell us that bereaved and survivors do not understand the 18-month delay in our bkc coming forward I could go on referring to other inquiries and report product make my point there's a widespread
00:27:14 make my point there's a widespread clamor for transparency in Canada to be addressed through substantive changes to the law the Parliament is already considered one such bill there's cross-party support for such change but
00:27:26 cross-party support for such change but in the context on context of these proceedings the rules and processes already allow for this problem to be taken on head-on to a significant degree you've listened to our submissions at
00:27:38 you've listened to our submissions at the outset of the inquiry and you've begun to utilize position statements and required for all nine stains in the light of the lack of meaningful responses setting out acknowledged
00:27:49 responses setting out acknowledged failings we submit that those requirements must now be ramped up 18 months down the line the enquiry the survivors and bereaved the community are
00:28:00 survivors and bereaved the community are all entitled to expect full and unequivocal assistance from institutional and corporate CPS and now not in a year's time or even later than that with the repeated invocation
00:28:13 that with the repeated invocation this is a matter for Phase two and that's a matter to be reviewed down the line one of the imperatives in undertaking a public inquiry is cost and efficiency
00:28:24 efficiency the reason some public inquiries and iconic inquests have taken so long isn't because of complicated subject matter it's because of an inability or unwillingness to confront this endemic
00:28:36 unwillingness to confront this endemic lack of institutional or corporate candor I started by saying that this was a disaster made by human beings the inquiry has powerful weapons at its disposal to require candor if it
00:28:48 disposal to require candor if it develops them this process will reach robust conclusions far more swiftly to the benefit of all both the public authority and private corporation CPS here have had disclosure of the detailed
00:29:00 here have had disclosure of the detailed expert reports they've had the opportunity for proposing questions through CGI to those experts although there's more investigation to be done additional expert opinion to be obtained
00:29:12 additional expert opinion to be obtained none of the public or private institutions and corporations can be in any doubt whatsoever what the issues are that affect them the issue with which this inquiry all of us requires
00:29:23 this inquiry all of us requires assistance they should be unequivocally asked to set out what went wrong in the areas of product promotion design procurement fabrication build site work
00:29:35 procurement fabrication build site work maintenance and management regulation for which they were responsible or in which they were engaged as mr. Friedman made clear this morning this isn't a process of determining liability but it
00:29:48 process of determining liability but it does involve getting to the truth and that includes accountability and it includes judgmental conclusions and in approaching the investigation in this way the inquiry will be able to focus
00:30:00 way the inquiry will be able to focus its work far more efficiently we urge you to address candor in the phase one report not only with respect to what we say is the institutional defensiveness of the lfb but also with an eye to the
00:30:12 of the lfb but also with an eye to the public authorities and corporate cps we will enter the spotlight more in Phase two this is a key issue and respectfully it should not be ducked the LF be
00:30:23 it should not be ducked the LF be systemic failings for the rest of my submissions I'm going to focus on the lfb because that's where the evidence is mainly be and what we say are the
00:30:34 mainly be and what we say are the systemic failings that contributed to the disaster given the imperative to try and complement rather than repeat submissions I'm directing my approach to contingency planning and response to
00:30:47 contingency planning and response to emergency calls evacuation and FSG calls respectively because they're central to the failures in its recent 24th of October position statement where it purports to set out
00:30:59 statement where it purports to set out lessons learned or more precisely the actions it's taken since the fire and today in oral submissions lfb says it's an organization committed to improvement
00:31:10 an organization committed to improvement and learning it asserts that its review team has 30 dedicated staff there are some sensible nods which we applaud to practical changes searching such as the
00:31:22 practical changes searching such as the rolling out of smoke words consideration of the greater use of drones smoke curtains for example but other than fleetingly and that be failed to address the two
00:31:34 and that be failed to address the two central issues we focused upon and to which I'm going to turn the lack of contingency planning for Wednesday port breaks down or in the language of the National guidance I'm going to turn to
00:31:45 National guidance I'm going to turn to in a minute became quote untenable and the fact that the Elat the FSG process was not fit for purpose for a significant incident with more than a
00:31:56 significant incident with more than a handful of FSGS and critically that this was a fact that was known to lfb before the fire why are these central issues notable really by their absence from the
00:32:09 notable really by their absence from the position statement of the lfb of course they refer to reviews to their policies 633 and 790 high-rise fire fighting and
00:32:20 633 and 790 high-rise fire fighting and FSG policies respectively but if they're included in those reviews why these issues not expressly highlighted and taken on head-on they're obvious and they've been
00:32:33 head-on they're obvious and they've been repeatedly referred to by us on behalf of the briefed and the survivors and taken up in questions by your counsel and that be no misunderstanding I mean
00:32:44 and that be no misunderstanding I mean that had there been proper contingency planning in place had it that not adhere to an obviously failed stay put and rescue plan rather than a plan B
00:32:55 rescue plan rather than a plan B evacuation then outcomes would doubtless have been different many more lives would have been saved in the written
00:33:06 would have been saved in the written closing LFP has a whole section headed evacuation and paragraph eighty-five makes the following assertion quote well well it's still the brigades position
00:33:18 well it's still the brigades position that the statutory guidance makes no provision within the type of building design used in Graham for for anything other than a stay put strategy the brigade is considering amendments to
00:33:29 brigade is considering amendments to these policy notes to provide additional guidance to cruise officers and control room operators that said the brigade wishes to emphasize that there is no simple and expedient plan B for
00:33:40 simple and expedient plan B for implementing a full-scale simultaneous evacuation plan when a catastrophic failure occurs the perplexing thing about this assertion is that the
00:33:51 about this assertion is that the statutory guidance of course refers and relates to the Building Regulations the real issue for the fire brigade shouldn't be whether that guidance helps
00:34:03 shouldn't be whether that guidance helps but whether the national guidance for fire and rescue services on firefighting and high-rise buildings mentions evacuation when stay port breaks down and unremarkable it most certainly does
00:34:15 and unremarkable it most certainly does however not only do the fire brigade failed to mention JRA 3.2 in the section on evacuation they fail to mention it at all in the whole of their closing
00:34:27 all in the whole of their closing submissions I'm going to come to JRA 3.2 in a moment but first contingencies more generally what do we mean by contingencies and contingency planning
00:34:39 contingencies and contingency planning it's a general proposition the stay-put strategy has been effective as we've heard in high-rise residences whereas the certainly discussion to be had as to whether stay put has had its day it was
00:34:51 whether stay put has had its day it was not unreasonable as at 14th of June to have a stay port to have stay put as a strategy for many high-rise residences so long as they didn't have dangerous cladding and effective fire safety
00:35:03 cladding and effective fire safety layers
00:35:03 layers however emergency services by their nature do not live in the world of the general than normal and the ordinary of course there are many types of fire that
00:35:15 course there are many types of fire that fire brigades will see as a matter of routine chip pan fires kitchen fires fires in bins but equally emergency services know that you must deal with the unexpected the plane or train crash
00:35:29 the unexpected the plane or train crash explosions suicide bombings sinkholes bridges collapsing natural disasters extreme weather all of these require not just default planning but contingency
00:35:40 just default planning but contingency planning and versatile and rapid in position of control and command decision-making although stay-put has been an effective strategy in many high-rise residences
00:35:52 strategy in many high-rise residences breakdown in compartment ation and large-scale facade fires are hardly unheard of lack and all and a host of other disasters and near disasters have been referred to already fires both in
00:36:04 been referred to already fires both in the UK and internationally indeed in the evidence we've seen the tall building fires presentation provided by lfb itself distinguished we might add by its
00:36:17 itself distinguished we might add by its lack of circulation but it's certain certainly recognized the phenomenon of dangerous high-rise fires and fire spread across fires that facades with new building materials of course we can
00:36:29 new building materials of course we can all distinguish as has been attempted between these fires and Grenville and of course the loss of life here was indeed unprecedented in UK terms but that stay
00:36:41 unprecedented in UK terms but that stay put was not infallible was well known we don't need the LFP presentation on that on spectacular high-rise fires or even lacan all for that fact we just need to
00:36:53 lacan all for that fact we just need to look at GRA 3.2 GRA 3.2 is national guidance for the fire and rescue services from central government the generic risk assessments are produced to
00:37:04 generic risk assessments are produced to minimize inconsistencies of approach and out
00:37:06 out across different fire and rescue services and to assist in meeting the requirements of the management of Health and Safety at Work Regulations 1999 that's expressly asserted in the
00:37:18 that's expressly asserted in the document not sure we've looked at but it's the GRA introduction document on open source introduces the whole series more than that page six of GRA 3.2
00:37:32 more than that page six of GRA 3.2 acknowledges that the guidance was issued consequent to a number of improvement notices issued by the Health and Safety Executive to phone rescue services regarding high-rise
00:37:43 services regarding high-rise firefighting systems and I emphasize the word and equipment does these central government generic risk assessments are key documents underpinning and informing
00:37:55 key documents underpinning and informing local services and policy from assistant commissioner rose evidence it's clear that the lfb were key stakeholders in the drafting of GRA 3.2 we've set out in
00:38:07 the drafting of GRA 3.2 we've set out in writing in the submissions that key passages from GRA 3.2 indeed we noted some of them in opening as well what gr e 3.2 does is set out the definition and
00:38:18 e 3.2 does is set out the definition and basis for staple evacuation strategy for that's what it was an evacuation strategy but it makes it completely clear that contingency planning is required it's axiomatic that emergency
00:38:30 required it's axiomatic that emergency services have to expect the unexpected react to the particular circumstances and that's why they have tools like the decision-making model which trains
00:38:41 decision-making model which trains guides commanders to gather evaluate set objectives and tactics communicate them continually reassess and reevaluate it's equally clear in this context high-rise
00:38:53 equally clear in this context high-rise residential buildings that national policy requires actual operational contingency planning in advance and expressly contemplates that there'll be a circumstance where stay put is quote
00:39:06 a circumstance where stay put is quote untenable and the Fire and Rescue Service will have to move to actual full or partial evacuation whether simultaneous or staged that's a expressly set out in this
00:39:18 that's a expressly set out in this national guidance document the possibility of stay-put becoming untenable real contemplated expressly referred to in guidance not some fantasy
00:39:29 referred to in guidance not some fantasy so far from reality that no one could reasonably expect it to countenance it not some spacecraft crashing into the short GRA three-point-two matrix
00:39:42 short GRA three-point-two matrix included and itemized the eventualities that in fact materialized on 14th of june and it provided control measures and mitigation in relation to them let
00:39:53 and mitigation in relation to them let me pick up some of the key points firstly page 8a caution that poor maintenance may mean that fire engineered solutions might not actually work the granville this was the case
00:40:05 work the granville this was the case although we might add poor compliance to poor maintenance specifically with relation to the lifts and other installations fire doors for example
00:40:16 installations fire doors for example secondly page 9 clear reference to rapid fire and smoke spread vertically up and down and horizontally and breach of compartment ation with fire spreading
00:40:27 compartment ation with fire spreading some multiple floors that's exactly what happened on the night and that's a factor that we referred to this morning as if it was something that couldn't have been force foreseen thirdly page 10
00:40:40 have been force foreseen thirdly page 10 mention of smoke stacking and how this can mislead as to location size of the fire fourthly pages 16 and 17 of the guidance but the need to understand the
00:40:51 guidance but the need to understand the evacuation protocol for the building and also to have an operational evacuation plan as a contingency where stay port becomes untenable as clearer references
00:41:02 becomes untenable as clearer references could be to the known possibility of the default strategy becoming ineffective and of course on the night just such eventualities arose a stay put became an
00:41:13 eventualities arose a stay put became an untenable compartment ation broke down but there was no plan B for the likes of mr. down to operate Billy page 18 local fire and rescue services required to
00:41:25 fire and rescue services required to have effective arrangements to deal with safe safety guidance calls and also to deal with the evacuation of the Abell mobility challenged ill injured
00:41:36 Abell mobility challenged ill injured residents FSG arrangements must include consideration of how advice will be reevaluated in the light of calls and how the information loop between caller
00:41:48 how the information loop between caller control and incident command will be achieved something I'll return to in a moment on the night there of course multiple FSG calls but as will submit later arrangements were neither
00:41:59 later arrangements were neither effective nor did they lead to any reevaluation of tactics until far too late furthermore no plan no policy to assist vulnerable residents to get out
00:42:11 assist vulnerable residents to get out and no firefighter lifts by which to do so and of course you've heard firsthand evidence from some of those mobility and disabled challenged residents including
00:42:24 disabled challenged residents including my client maja Qadir sixthly at page 20 express mention that incident commanders should be trained to identify when evacuation should prevail
00:42:35 identify when evacuation should prevail where stay put is the default strategy it's apparent from the evidence that this didn't happen at the London Fire Brigade 7 page 21 incident commanders
00:42:46 Brigade 7 page 21 incident commanders should review and change the plan when new information becomes available at the incident or from control vital that incident commanders utilize functional commanders to the full 8th Lee instinct
00:43:00 commanders to the full 8th Lee instinct owners must recognize we're building designer materials may be impacting on fire spread specific mention made of plastic or aluminium window frames and panels it's apparent no awareness on the
00:43:13 panels it's apparent no awareness on the night 9th Lee section 2 of the summary to the guidance document at point 23 reference again made to the evacuation of the building made necessary by reason
00:43:27 of the building made necessary by reason of state court becoming untenable due to an expected fire spread and control measures raised including quotes utilizing other emergency services to
00:43:38 utilizing other emergency services to aid movement of casualties in the public to safe areas and reply and relying upon quote all means of contacting within the buildings such as intercom telephones loudhailer zet cetera
00:43:51 telephones loudhailer zet cetera interestingly GRA 3.2 raises just the points that we've looked at in evidence and to which I'll return for which are dismissed by the London Fire Brigade the approach envisaged in GRA 3.2 is classic
00:44:05 approach envisaged in GRA 3.2 is classic contingency planning it contemplates a practical workaround to a default safety strategy which has failed contre distinction LF B's high-rise residential
00:44:16 distinction LF B's high-rise residential building firefighting policies do not follow through and equip incident commanders to evaluate the necessity for abandoning and stay port policy and didn't invoke any contingency plan to
00:44:28 didn't invoke any contingency plan to him evacuate indeed Allah P do not have any contingency planning policy for high-rise residential blocks where there's a breach of complementation at all
00:44:39 all policy six three three repeatedly refers to rescue a multiple rescue and only at paragraph 745 does it refer to the possibility of evacuation then only to
00:44:53 possibility of evacuation then only to point at the difficulty of so doing no contingency plan no plan B no guidance on how an incident commander should evaluate abandoning the default position no guidance on how evacuation might be
00:45:05 no guidance on how evacuation might be achieved what factors would assist such as immediately informing control so that advice can be changed and the specific measures referred to in GRA 3.2 as we've
00:45:18 measures referred to in GRA 3.2 as we've heard in evidence compounding the lack of policy around contingencies absolutely no training on evacuation from high-rise blocks no submission Perrigo 85 of the written closing by L
00:45:30 Perrigo 85 of the written closing by L epi is somewhat in disingenuous when it states that the statutory guidance makes no reference to evacuation as a required contingency to staple when it fails as
00:45:43 contingency to staple when it fails as the alleppey know full well that the national guidance most applicable is gra 3.2 not least because of the part they played in drafting it the lack of reference to GRA 3.2 in the submission
00:45:56 reference to GRA 3.2 in the submission speaks volumes this a public forty which is trying to assist the inquiry or is this a public authority which is avoiding obvious and serious failings in its systems and in its
00:46:09 failings in its systems and in its operations on the night yes there's reference to welcome positive changes and some public policy reviews but nowhere does Elif be properly grapple
00:46:20 nowhere does Elif be properly grapple with the key issues given that the GRA s are not only national guidance to assist in the saving of life but they were expressly promulgated to assist fire and
00:46:33 expressly promulgated to assist fire and rescue services it discharged their duties under health and safety regulations the failure of alleppey to follow through with appropriate policies and training is an our submission a
00:46:44 and training is an our submission a clear breach the general article to be duty to have a reasonable policy to minimize the life-threatening risks of a known dangerous scenario both g4 and g3
00:46:56 known dangerous scenario both g4 and g3 have referred to this in written submissions and we've thought noted a whole host of authorities regarding that proposition if it's thought to be in any way controversial we urge you to clearly
00:47:07 way controversial we urge you to clearly identify the systemic failures in the interim report the MFP position and that of some of its senior officers is that evacuation was not possible or quote
00:47:19 evacuation was not possible or quote virtually impracticable essentially we say that's an attempt to avoid the question we've heard that the building was quote not built for evacuation no
00:47:31 was quote not built for evacuation no means of communication conditions deteriorating difficult it might have proved problematic a single staircase and no general alarm might have been but facing the inferno that the tower
00:47:43 facing the inferno that the tower rapidly became there was simply no option the successive evacuation would have been directly related to how soon it was put into effect and how efficient it was it can't be really disputed that
00:47:56 it was it can't be really disputed that early evacuation would have saved many lives we asserted as much in opening we underlined that submission following the evidence before I turn to the evidence I
00:48:08 evidence before I turn to the evidence I note in passing the recent opinions of Professor person supporting the work of dr. lane regarding evacuation times would it be impossible and how long would it have
00:48:19 impossible and how long would it have taken mr. Friedman's referred to the 7 minute point to another place in a slightly different context professor pursue refers to 15 minutes we fully
00:48:32 pursue refers to 15 minutes we fully understand the difficulties of an evacuation Graham felt out but the single staircase the conditions would not have been ideal but there was no
00:48:43 not have been ideal but there was no absolute safety issue with simultaneous evacuation it was not impossible to do and it would have been unlikely to have impacted or been impacted by the
00:48:55 impacted or been impacted by the operations of the firefighters and obviously the firefighters would have played an important role in facilitating the evacuation particularly the elderly and the vulnerable it was a matter of organizing it
00:49:06 organizing it it's an unattractive position for the lfp to speak of virtually impracticability when that made that morning they appear to have given it scant consideration and no policy
00:49:18 scant consideration and no policy consideration the evidence Stephane bar wise and Danny Freeman have set out the facts and chronology and therefore I'm simply going to cherry-pick a few times
00:49:31 simply going to cherry-pick a few times from 1:08 subjectively according to the experts the fire had escaped or was about to escape onto the cladding objectively within a short time
00:49:42 cladding objectively within a short time a very short time any chance of stopping the fire was impossible from Professor Bisbee's compilation number one we can see by observation that the fire is
00:49:53 see by observation that the fire is raging out of control certainly by 115 by 126 the fire was almost the whole height of the building from level 4 to level 23 along b5 column a height of
00:50:07 level 23 along b5 column a height of over 50 meters compartment ation had been breached on a number of levels and dr. Lane of course the pines that stay port was untenable from at least this point but the key is when subjectively
00:50:21 point but the key is when subjectively the incident command should have realized that the building was compromised on different levels when the fire was out of control in our submission this was not a binary moment
00:50:32 submission this was not a binary moment the realization should have begun to fall soon after 108 as the fire rapidly spread and as the minutes went by the
00:50:43 spread and as the minutes went by the incident command should have had well in mind that the fire was reaching a stage where it was not safe for residents to remain and should have formed a decisive plan which would have commenced a
00:50:56 plan which would have commenced a determined evacuation at the very least by 126 every minute thereafter is relevant when we speak of their alert B's institutional failure to get
00:51:07 B's institutional failure to get residents to safety sure enough we've heard evidence that with a facade fire it might burn off without re-entering given this was a densely populated high-rise residential block one
00:51:20 high-rise residential block one stairwell
00:51:21 stairwell in the height of summer when windows would naturally be open and the fire rapidly spreading with information available and coming from firefighters inside the building that fire and smoke has spread internally with calls
00:51:33 has spread internally with calls starting to come in from imperiled residence the point when it should have been obvious that stay put was no longer tenable must have been very early if that wasn't 115 or there there abouts
00:51:44 that wasn't 115 or there there abouts when the fire was plainly spreading out of control it was most certainly by 126 we reject the suggestion that this is based on hindsight it should have
00:51:55 based on hindsight it should have followed from observation gathering information from the fire ground and from applying the DMM gather assess reevaluate determine objectives make plans communicate them control the
00:52:06 plans communicate them control the activity if it was obvious to police officers like PC Sangha at 128 approaching the tower who radioed that the police should prepare for evacuation
00:52:17 the police should prepare for evacuation why was it not obvious to the lfb mr. Freeman's alluded to the invidious position mr. Dowden was in within minutes of his arrival the fire had
00:52:28 minutes of his arrival the fire had escalated well beyond that which a watch manager manager is expected to command the practical fact that senior officers were
00:52:36 were not on the ground for some time was not mitigated by remote advice of support something that was envisaged not only within the mobilizing policy for one too but was also something that would have
00:52:48 but was also something that would have been triggered by an early declaration of a major incident by the LFP through the strategic response arrangements in policy six nine nine which would have immediately stood up Gold Command and
00:53:00 immediately stood up Gold Command and the commissioners group the scant evidence of any attempt by senior manager to assist before arrival which meant that a watch manager was left in charge for the almost the whole of the
00:53:11 charge for the almost the whole of the golden hour of emergency response opportunity indeed this has been stated it was not until mr. Roe arrived at 243 when any proper command and control was
00:53:23 when any proper command and control was established where therefore why therefore no mention in the lfb closing statements of how they intend to ensure that they never put a watch manager in
00:53:34 that they never put a watch manager in that position again why indeed policy including four to four did provide for a monitoring officer and although that post was assumed no support was in fact
00:53:47 post was assumed no support was in fact given by mr. Walton who was the monitoring officer designate until he arrived but the incident ground around 150 with rapid escalation directed by
00:54:00 150 with rapid escalation directed by mr. down a DAC assisted by an AC should have taken over at 10 pumps but nothing of the kind happened in the meantime no effective commanding control support no
00:54:12 effective commanding control support no contingency policy or training the default strategies of stay put and defend in place were continued in the face of overwhelming evidence that they weren't working why because as we've
00:54:24 weren't working why because as we've seen policy and training did not equip the responders to consider or change to a contingency evacuation because no external command and control support was
00:54:35 external command and control support was provided to mr. Dowden because a watch manager was left in charge of a fire that was so far beyond his capability but he didn't want to do we've set out the facts relating to mr. down
00:54:48 the facts relating to mr. down nineteen of our written submissions and I don't repeat them here the two instinct commanders following mr. Dowd and mr. Walton and mr. Roper Lachlan fared little better until relieved at
00:55:02 fared little better until relieved at 243 mr. Lachlan indicated that he had no expectation that flats other than on the northeast side would be affected or that compartment compartment Asian had failed
00:55:15 compartment compartment Asian had failed he turned his air wave off as he approached the tower and he didn't consider he needed details of the FSG calls to formulate a plan indeed shortly
00:55:26 calls to formulate a plan indeed shortly before he was before the position was taken by mr. roe mr. Ola Curran noted his surprise of being told the number of persons reported it was the incident
00:55:39 persons reported it was the incident commander to change from state court to evacuation and to determine that FSG callers were to be advised to get out if they could the further 45 minutes were wasted because miss roe Lachlan failed
00:55:51 wasted because miss roe Lachlan failed to get situational awareness such that he could have properly evaluate what to do call so that what officers has been mentioned did have such awareness mr.
00:56:02 mentioned did have such awareness mr. Harrison mr. Egan mr. Goodell all of whom on arrival expressed that they thought evacuation would follow their on
00:56:15 thought evacuation would follow their on assuming command mr. roat no convincing at all that it was quote absolutely unsustainable to continue with stay put so much for what happened but what could
00:56:27 so much for what happened but what could have happened there are the Ala P correct that evacuation was virtually impractical given the reality that there was really no alternative had the default position
00:56:39 no alternative had the default position being abandoned by or around 126 and it's determined evacuation imposed attention would then being focused on how to overcome the difficulties of a
00:56:50 how to overcome the difficulties of a single staircase in no general alarm and a raging fire not if first the bridgehead would have been informed that all efforts would be made to evacuate sort of meant that resources would not
00:57:03 sort of meant that resources would not have been wasted trying to get onto the roof in moving firefighting media around every effort could have been made to maintain the integrity of the stairs that be a crews would have been deployed
00:57:15 that be a crews would have been deployed to systematically clear floors as soon as they derived using high-rise kit to mark those flats and floors cleared rather than awaiting debriefs for ad hoc
00:57:26 rather than awaiting debriefs for ad hoc rescues secondly control would have been informed to change advise to call us to get out if you can and to bang on neighbors doors if possible control
00:57:37 neighbors doors if possible control could have been asked to ring previous callers back and tell them to to immediately contact RB Casey and the team o to see whether they could recruit some sensible assistance with lists of
00:57:49 some sensible assistance with lists of vulnerable residents in particular thirdly a firefighter or a police officer could have been stationed on the intercom I appreciate the problem with
00:58:01 intercom I appreciate the problem with falling debris has been raised but the immediate area the reality is the immediate area near the entrance had no such falling debris for a considerable period it was covered by a canopy it
00:58:14 period it was covered by a canopy it wasn't compromised for a considerable time into the night from CCTV camera fall if this was certainly after 2:30 from mr. Bisbee's video number five it
00:58:27 from mr. Bisbee's video number five it was probably after 2:40 so plenty of time in our submission to have a person safely stationed at the buzzers firefighters or a police police officers could have been stationed around the
00:58:38 could have been stationed around the block with loud tailors or as mr. Friedman's already mentioned inside the block - despite some assertions of the contrary there is open-source YouTube
00:58:50 contrary there is open-source YouTube footage from the night illustrating that a loud hailer at the base of the tower could be heard from the 23rd floor and we've referred to that in our written submissions of paragraph 35 it indicates
00:59:03 submissions of paragraph 35 it indicates that loud Ahlers could have been effective at least to some degree incidentally the YouTube clip is apparently picking up the loud hailer used by firefighter Murray
00:59:14 used by firefighter Murray a firefighter that has been read but not called to give evidence and as a time of 140 so in our submission it was perfectly possible from an early point to use tools such as loudhailer
00:59:28 to use tools such as loudhailer furthermore em pass evidence about aerial support indicates that helicopters are equipped with PA systems which could have also been deployed for
00:59:39 which could have also been deployed for this purpose at least such efforts would have alerted residents to the fire before it directly affected them even if they'd heard had trouble hearing the particular advice itself
00:59:50 particular advice itself fifthly the bridgehead or a small group of dedicated officers could have been tasked to identify which flaws were clear who'd been evacuated and where remaining residents particularly the
01:00:01 remaining residents particularly the vulnerable might be sixthly a major incident declaration and consequent coordination with the blue light service is the police and ambulance service in particular could have been deployed to
01:00:13 particular could have been deployed to identify who had evacuated but remained from inquiry at the base of the tower now even caroling evacuees to confirm their position and who is left in the
01:00:24 their position and who is left in the tower and as I noted earlier the intercom and loud hailer points are specifically mentioned in the National guidance the statistics show that half of the residents that our self evacuated
01:00:35 of the residents that our self evacuated by 142 dr. Lane reviewed the evidence and indicates that the stairs were largely clear prior to that time although there may be in some difficulties passing the hot zone between 13 and 16 between 2 o'clock and
01:00:49 between 13 and 16 between 2 o'clock and 2:30 there were multiple self evacuations and assisted rescues up to and beyond 4 o'clock including from above level 16 until around 355 although
01:01:01 above level 16 until around 355 although conditions undoubtedly deteriorated and at times particular levels became more difficult to pass the evacuation was possible for several hours what was missing was a coordinated plan or indeed
01:01:13 missing was a coordinated plan or indeed a plan at all FSGS a zing incident command persisted with firefighting and failed to reevaluate or abandon state port a parallel and almost
01:01:26 abandon state port a parallel and almost unconnected processed with the 999 calls without steer from instant command the control room continued blind with a process based on advice that's a state port and providing
01:01:39 advice that's a state port and providing information to the fire ground to facilitate individual rescues policies 5 3 9 and 790 deal with the handling of 999 calls and FSG calls respectively as
01:01:51 999 calls and FSG calls respectively as we know where the building evacuation started strategy is state port the caller will be told to get out if they become directly affected by fire or advised to stay put otherwise
01:02:02 advised to stay put otherwise underpinned by confidence in complementation and the ability to put the fire out but if FSG policy is to feed information from 999 callers where residents believe
01:02:14 from 999 callers where residents believe they're trapped as well to the fire ground to facilitate rescue whilst advising callers to continue as consider escape routes or otherwise remain safe
01:02:25 escape routes or otherwise remain safe so the aims of the policy are to provide the best informed life safety advice on the one hand and on the other to provide optimum details to the fire ground to facilitate rescue neither of those aims
01:02:39 facilitate rescue neither of those aims is achieved on the night nor was any information loop on the one hand resources were being wasted on other effort efforts which only exacerbated the problems whilst many residents who
01:02:51 the problems whilst many residents who still had a window of opportunity to self evacuate were being told to stay put a stay put been abandoned at all before 126 all the callers between then
01:03:02 before 126 all the callers between then and when the advice actually was changed sometime after 2 35 that would have been advised to get out if they could from our schedules the schedules that we provided last week this translates in
01:03:14 provided last week this translates in our submission to around 57 999 calls relating to 25 different flats instead what happened residents were told to stay port because no one at old control
01:03:26 stay port because no one at old control room have a change of policy no one at Olin complementation had been breached inquiries were not consistently made as to whether residents were becoming affected by heat fire or smoke and
01:03:38 affected by heat fire or smoke and whether they could leave the operation of the process was on any rational view hopeless but control they operated blind from the instant command
01:03:49 operated blind from the instant command scraps of paper whiteboards a mishmash of radio messages mobile phone and landline were used to communicate with the fire ground the fire ground messages were not initially picked up by the
01:04:01 were not initially picked up by the incident command appliance and they were diverted to a fire appliance on route the FSG messages the first FSG messages were received at the fire ground by this
01:04:12 were received at the fire ground by this cu8 at around 143 but just how they were collated there assuming they were remains unclear and likewise I though
01:04:24 remains unclear and likewise I though how they were passed on mr. Merrick in cu8 gave evidence that he communicated messages on to mr. Kent field and it may be some messages were forwarded directly to the watch manager to silver by radio
01:04:37 to the watch manager to silver by radio the scant physical record of what was happening to the information at this time save for the notes made by mr. maryk apparently as he received them we
01:04:49 maryk apparently as he received them we know and I reference the g3 be a deployment schedule here that no be a crew was deployed to any flat as a result of a 999 call or the FSG process
01:05:01 result of a 999 call or the FSG process while mr. Dowden was incident commander and early an hour into the fire the average delay through the night in deploying crews to flats to which crews actually were deployed on our analysis
01:05:13 actually were deployed on our analysis was an hour and 10 minutes from the time of the first nine nine nine four and I stressed a flat's to which deployments were actually made because almost half of them there
01:05:24 because almost half of them there weren't such deployments at 213 mr. Sadler apparently started his carbonic staging post literally with notes made on the back of an envelope
01:05:35 on the back of an envelope we timed that because of the picture he took of the envelope so he could pass it on to the tower it's not until 223 now hour and a half into the fire that the dedicated c7
01:05:47 into the fire that the dedicated c7 became operational for FSG management far far too late by that point about 24 of the 33 flats from which FSG calls were made had
01:05:58 from which FSG calls were made had called 999 at least once standing back from all this what was happening was efforts being made best efforts being made but chaos resulting staging post
01:06:10 made but chaos resulting staging post popping up at car bonnets and the entrance to the tower by mr. Williams and on the mezzanine scraps of paper backs of envelopes walls whiteboards used at these points and at the
01:06:21 used at these points and at the bridgehead to record information that then had to be moved about the fact that the FSG process failed should not be a surprise to anybody it certainly shouldn't have been a surprise to the
01:06:32 shouldn't have been a surprise to the lfb we know that from the evidence of mr. Johnson who told senior policy officers while he served on the dedicated command unit section what
01:06:44 dedicated command unit section what better place could here be at Islington in 2014 that policy to 790 was not effectively fit for purpose of melted
01:06:55 effectively fit for purpose of melted multi call incidents and he demonstrated it through a training package but regrettably his criticisms and proposals for change were not heeded Babcock's declined to take the training forward
01:07:06 declined to take the training forward the package demonstrated that it would be impossible to pass information on within the timescales of what was felt to be a realistic progression with a
01:07:17 to be a realistic progression with a high-rise incident in effect the training package showed that it was impossible to meet reasonable timescales and of course that was proved by the incident itself where there's one or a
01:07:29 incident itself where there's one or a small number of calls the control room will liaise with the instant command appliance and no doubt the instant commander direct and a remain on the line but a multi call incident the
01:07:42 line but a multi call incident the dedicated unit to deal with calls will have to get to the incident will have to set up communication will had to be established between the commander the bridgehead the command unit control the
01:07:54 bridgehead the command unit control the policy requires a loop where information comes from the caller to the incident ground is acted upon and a debrief goes back as we've seen from the evidence
01:08:05 back as we've seen from the evidence the FSG process on the incident ground was shambolic it took nearly 20 minutes from the first FSG calls for them to be notified to the incident ground no information was ever fed back to the
01:08:16 information was ever fed back to the control room if his policy intended the IC was reliably kept informed as a pivot point within the loop of information this in turn would have brought earlier and clearer focus upon the need to
01:08:28 and clearer focus upon the need to abandon stay port but in reality the incident commanders remained quite independent of the process at least until mr. ro took over far too late our
01:08:39 until mr. ro took over far too late our analysis of the evidence up to 4:15 in the schedules again which we provided to the inquiry team last week we indicate that only three deployments of
01:08:52 that only three deployments of firefighters resulting directly from FSG calls led to fully successful outcomes with another two which were partially as successful out of 33 flats from which
01:09:05 successful out of 33 flats from which 999 calls were made no rescue deployments at all were made in almost half of them of course in some of those cases residents eventually self evacuated and some matam were assisted
01:09:16 evacuated and some matam were assisted by firefighters in lobbies and on the stairway the point made is that the FSG process on the night was successful in only a handful of cases the fact that firefighters assisted residents in
01:09:28 firefighters assisted residents in lobbies and on the stairs supports the proposition the deployment - searching clear floors would have been far more effective neither does there seem to have been any correlation between calls
01:09:40 have been any correlation between calls which were noted as priorities in cu7 on the grid that you may recall where the LF B had information that trapped residents were elderly or children
01:09:52 residents were elderly or children immobile or ill and the deployments among the 16 999 calls where they were apparently no deployments at all eleven were noted as priorities on on the grid
01:10:05 were noted as priorities on on the grid finally in terms of the statistics we note that 22 emergencies recalls emergency calls have been received from 15 flats where the caller identified the
01:10:17 15 flats where the caller identified the flattened above 145 21 of those have passed to the fairground as FSG calls the significance of that by 125 all 999 calls identifying
01:10:29 of that by 125 all 999 calls identifying particular flowers were being passed on to the fairground and by 145 there were a huge number of them the fire was out of control the control room was overrun
01:10:40 of control the control room was overrun the FSG policy was not producing results and that continued through the incident there was a disconnect between command in the control room critically information flow was one way from
01:10:53 information flow was one way from control to the fire ground much of the information out of date by the time we got to the bridgehead or because of a lack of feedback from the tower so some information fell between the
01:11:04 so some information fell between the cracks and was not passed on despite callers being told that rescue is on its way
01:11:10 way incident command failed to appreciate the volume of course I'm conscious of time but I would like to finally move on to an example and that's the example of
01:11:23 to an example and that's the example of flat 140 on level 17 just how I'm fit for purpose the FSG policy was is illustrated by reference to flat 142 as
01:11:34 illustrated by reference to flat 142 as I've stated from mr. Johnson's evidence we know lfp were aware of how it wouldn't cope with multiple calls whether it's possible to have a workable
01:11:45 whether it's possible to have a workable FSG process to deal with multiple calls it remains in question but it's known deficiency should have underlined the need for a general evacuation the
01:11:56 need for a general evacuation the residents of flatworm for two were the family of my client Muhammad Hakim you may not be immediately familiar with one for two because there's been so little evidence about it little feature in the
01:12:08 evidence about it little feature in the next phase when we deal with what happened to each to cease deceased because the five members of the family and the flat perished in the fire but I'm not referring to one for two now for
01:12:19 I'm not referring to one for two now for that purpose but to illustrate how information fell between the cracks there were three 999 calls from flat 142 129 reporting smoke coming
01:12:31 129 reporting smoke coming to the flat at 2:27 reporting by then the fire was right next to the window and at 3:18 I just want to spend a moment tracing the evidence that we know
01:12:43 moment tracing the evidence that we know about that the first court was actually taken by the police of 129 and they passed it on to the fire brigade at 1:38 Control passed the information to the
01:12:54 Control passed the information to the fire ground as an FSG by radio but the in the incident commander plant didn't respond and the the information had to be intercepted by cu8 in the process of
01:13:05 be intercepted by cu8 in the process of setting up but 143 there doesn't appear to be in any system as I've said at CUA certainly at that point but at some time
01:13:16 certainly at that point but at some time before 2:17 the legend seventeenth floor 142 FSG did appear on the second floor bridge head wall we can be clear about
01:13:28 bridge head wall we can be clear about that extent of time because that's when the bridgehead was moved to the third floor so it's a reasonable conclusion that somehow the information and gone from controlled to see you ate to the
01:13:41 from controlled to see you ate to the bridgehead before that time there's no evidence that the flatworm for two information passed through mr. Sadler's car bonnet staging post or indeed mr. Williams is posted at the entrance to
01:13:53 Williams is posted at the entrance to the tower there's no evidence at all that the information went from the second floor to the third floor when the bridge had moved and it appears that the information passed on from this first
01:14:05 information passed on from this first call was lost so had been the best chance of rescuing the family when no one came a family made a second call almost an hour later at 2:27 at 2:30 at
01:14:20 almost an hour later at 2:27 at 2:30 at the control room officer who took the call passed the information to see you 7:00 mr. Peckham noted the radio transmission on a control information form so we know that was received we
01:14:32 form so we know that was received we know it was added to the laminated board in ECU seven there's no evidence however that that second call was communicated to the tower until much later on
01:14:44 to the tower until much later on mr. Finnell took a photograph of a laminated board to the tower sometime up to a quarter past three again the family waited and no one came at 3:18 the
01:14:56 waited and no one came at 3:18 the family made the third call spoke to the same CRO a control information former game was generated 3:23 so we know the information was passed on cu7 were also
01:15:09 information was passed on cu7 were also informed independently by the police pc jacobs that five people were trapped in flat 142 just after this time at 3:35 that too was recorded on a CIF this
01:15:23 that too was recorded on a CIF this information did appear to go to the tower because it ended up on the bridge bridgehead on the ground floor but by the time this third 999 call it was too
01:15:34 the time this third 999 call it was too late because the last crew has successfully reached level 17 had been deployed there somewhat earlier despite three 999 calls information being passed to see you 8 twice to see you 7
01:15:47 to see you 8 twice to see you 7 independent police evident information going to see you 7 no rescue crew was ever deployed to flat 142 lost between
01:15:58 ever deployed to flat 142 lost between the cracks conclusions long before the firefighters could have been deployed onto the firing flat 16 it had escaped onto the cladding from a very early
01:16:10 onto the cladding from a very early stage it was obvious that no means of fire fighting was going to extinguish or slow the progress of the fire the fire brigade failed to react appropriately because a series of systemic errors we
01:16:23 because a series of systemic errors we urge the enquiring not to confuse effort without come very brave attempts were being made to save lives but commanders were following the wrong plan with policies that were plainly not fit for
01:16:35 policies that were plainly not fit for purpose 633 no mention of the possibility of the need to evacuate where stay pork was the default policy so he mentioned may of the possibility
01:16:47 so he mentioned may of the possibility of the need to evacuate but no contingency or operational plan for how that could be a urged this compounded by the complete absence of training given the scale of
01:16:59 absence of training given the scale of the disaster it's apparent that the FSG system never got off the ground that no stage worked of efficiently and was ineffective in saving lives in fact in
01:17:10 ineffective in saving lives in fact in it hearing to a plan that was playing inappropriate from the outset the FSG process hindered rather than helped the LF be alright to highlight the courage of individual
01:17:23 to highlight the courage of individual firefighters but they do them a disservice when they fail to acknowledge the obvious systemic errors which placed those firefighters as well as residents that greater risk to life and limb those
01:17:35 that greater risk to life and limb those systemic failures are all the more serious because lfb had been involved in drafting the national guidance a new post lack and all the policy fix and
01:17:48 post lack and all the policy fix and with the FSG policy simply didn't work for an incident with more than a handful of attract persons we urge you to carefully consider the following
01:17:59 carefully consider the following findings firstly that there was a systemic failure to have any contingency plan to safeguard life whereas des portes strategy became untenable or trained to evaluate or operate such a
01:18:11 trained to evaluate or operate such a plan secondly that there was a systemic failure to properly gather collate make available sufficient information concerning the m4 tower to allow for such contingency planning and operation
01:18:23 such contingency planning and operation thirdly that those systemic failures led to the failure to take decisive action to safeguard life by evacuating the tower from about 126 and lastly that the
01:18:36 tower from about 126 and lastly that the FSG policy 790 was known to be unfit for purpose prior to the fire and indeed failed on the night those are our submissions well thank you very much
01:18:47 submissions well thank you very much indeed
01:18:48 indeed that might be a convenient point I think to have a ten-minute break give the transcribers fingers at rest so we'll break down and come back start
01:19:00 we'll break down and come back start again at twenty five to four please thank you
01:19:03 thank you thank you very much
01:25:24 you
01:32:04 you
01:32:37 no mr. Steen your turn to make statement before you start can I just say that we're probably starting is now which you hadn't originally expected to start at I
01:32:49 hadn't originally expected to start at I don't want you to feel rushed it would be probably good for us and good for you to hear the whole of your statement at once but if we get to a time when you feel it's not gonna work you tell me sir
01:33:03 feel it's not gonna work you tell me sir I understand that I've already spoken to a stenographer about the need to keep to a reasonable pace of Noelle's heart bear those matters in motion we'll see how he goes me sir the London Fire Brigade let
01:33:19 goes me sir the London Fire Brigade let down the firefighters who attended the rain fall tower fire as well as the residents of the Granville Tower quite simply the lfp was not able to take on a
01:33:31 simply the lfp was not able to take on a fire of this magnitude as it had had insufficient training inadequate equipment and no leadership capable of tackling this fire the underpart brigade
01:33:43 tackling this fire the underpart brigade was a disorganized organization the evidence before this inquiry has demonstrated that the London Fire Brigade has a cultural inability to plan
01:33:55 Brigade has a cultural inability to plan for a major disaster in any high-rise block whether residential or office or any large building it has completely
01:34:06 any large building it has completely failed to train or test equipment such as radio and other communication systems under true-to-life conditions the
01:34:20 under true-to-life conditions the majority of the equipment which is meant to allow the London Fire Brigade to communicate analyze and assess a fire ground did not work and the London Fire
01:34:34 ground did not work and the London Fire Brigade has demonstrated an inability to be able to grasp and learn from mistakes
01:34:42 instead what we have from the commissioner at the end of her evidence on the 27th of September of this year is the much quoted comment that she
01:34:53 year is the much quoted comment that she would not change anything we did on the night the Commissioner Danny cotton should have been well aware of the dreadful failings within the fire
01:35:04 dreadful failings within the fire brigade which had been identified before this inquiry by the time she came to give her evidence we suggest that there
01:35:15 give her evidence we suggest that there has been a failure to consider the unfolding evidence before this inquiry by both the commissioner and her leadership team we suggest that they are
01:35:27 leadership team we suggest that they are not fit to run the London Fire Brigade
01:35:32 this condemnation of the leadership of the fire brigade for London should not be taken to be an insult to those on the front line
01:35:44 front line no one can or should forget the sheer bravery and determination of the individual firefighters who risked their lives within the Grand ville tower our
01:35:57 lives within the Grand ville tower our thirty quotes now from two of those brave firefighters crew manager Christopher Secret in his evidence he
01:36:09 Christopher Secret in his evidence he referred to the struggle to get out of the bin store he was hot disorientated and stressed eventually we got out and got to a stairwell the smoke was thick
01:36:22 got to a stairwell the smoke was thick in the stairwell and he couldn't see his hand in front of his face we had all lost our energy we struggled to get down the stairs and it was a mixture of stumbling falling and crawling trying to
01:36:34 stumbling falling and crawling trying to get down after coming down three or four floors I realized we had lost firefighter Chris doggy I asked firefighter pardillo to shout for
01:36:46 firefighter pardillo to shout for firefighter dog you because I have no energy to do it neither did he we sat there i looked at my gauge and i saw i only had 15 bar left i was in big
01:36:59 only had 15 bar left i was in big trouble
01:37:01 trouble I put myself in a corner of the stairwell because I did not want to be in anyone elses way if I didn't make it out
01:37:14 in fact firefighter dog who appeared grabbed his arm and was able to help him out let's not forget the evidence from
01:37:26 out let's not forget the evidence from watch manager Louisa de Silva now we'll recall that she was deployed at the bridgehead faced there with the job of making sure that
01:37:38 there with the job of making sure that firefighters going correctly into the tower question was asked of her by counsel to the inquiry referred to to West Hampstead ba wearers Martin hall
01:37:51 West Hampstead ba wearers Martin hall and Matthew Taylor being deployed at roughly 255 she was asked what her recollection was about that particular deployment she said this what I remember
01:38:04 deployment she said this what I remember about that is I recognized them like I say because of my time she'd refer to at Kentish Town so they were firefighters who are familiar to me what I do
01:38:15 who are familiar to me what I do remember is firefighter 10 are asking me if there would be water there when he gets there any firefighter going near into a fire will take water that is a baseline for our safety and I remember
01:38:29 baseline for our safety and I remember him asking I remember having to say that it was unlikely there would be any water for him to take with him into those conditions she went on these are firefighters who have seen the building
01:38:40 firefighters who have seen the building they're entering I remember having to say to him that it was unlikely there would be water but yet he was to try and effect rescues mr. silk sorry mr. Silva
01:38:53 effect rescues mr. silk sorry mr. Silva was sending firefighters into an inferno and she and they knew it but this inquiry needs to avoid the mistake being made by the London Fire
01:39:05 mistake being made by the London Fire Brigade which is to confuse bravery with adequacy of response bravery cannot replace training and bravery is no substitute for
01:39:16 and bravery is no substitute for equipment nor should any of us forget the astonishing courage of the residents of the town both those who made it out and those who died in the fire in the
01:39:31 and those who died in the fire in the last part of the evidence read before this inquiry on the 3rd of December the words of mrs. Emanuel Ax the sorrow and the mother of Gloria Trevisan who lost her life alongside a boyfriend Marco
01:39:42 her life alongside a boyfriend Marco guitar D and two others in flat to hunt 202 on the 23rd floor should be remembered Gloria said to her mother you could tell she was having problems
01:39:53 could tell she was having problems talking her throat was burning she was starting to feel unwell and she wanted to go quicker at a certain point she told me the fire was coming through the window the moment later she said she
01:40:07 window the moment later she said she couldn't breathe she told me again what she felt for us and that we have to say goodbye and we had to be strong that boy at that point Gloria said she was cutting off the phone because she didn't
01:40:18 cutting off the phone because she didn't want me to hear anything and she said it could bye to us firefighters and residents have no doubt about the bonds that have been made amongst themselves
01:40:30 that have been made amongst themselves they know what they saw what they witnessed and they have built up strong relationships of friendship and respect that is why when the resident and
01:40:42 that is why when the resident and survivors march on the 14th of a month the firefighters lined the March and they meet and greet each other with dignity warmth and respect but there are
01:40:55 dignity warmth and respect but there are difficulties for residents and family members from the tower residents of how new members from the tower and survivors from this fire even when they don't
01:41:06 from this fire even when they don't always believe that individual firefighters either did their best or have even given their evidence honestly because of the dire peril everyone was
01:41:17 because of the dire peril everyone was in they thanked firefighters for their saving of lives an example of this is Shawn to Larbi he said I'd like to speak about the fabric
01:41:28 about the fabric if I can no one should ever have to go to work and not return back to their family no one whether your fire brigade whether you're a firefighter whatever job you do but at the end of the day
01:41:41 job you do but at the end of the day you'll be easier sometimes if you just say the truth because that way people will forgive you it will be easier for people to forgive you he went on to say
01:41:53 people to forgive you he went on to say you shouldn't lie in residents that are going through enough as it is and say that you did rescue mission missions that you didn't do and of this position
01:42:04 that you didn't do and of this position which is difficult for mr. Lobby we suggest he says I would like to thank Peter Herrera the firefighter for opening the door because if he didn't open that door I probably would have
01:42:15 open that door I probably would have gone through the window and I probably would have died but at the same time mr. Herrera made loads of mistakes that night and all he in fact had to say was
01:42:27 night and all he in fact had to say was I tried my best but I was scared where we suggest that the London Fire Brigade has failed as an organization from a
01:42:39 has failed as an organization from a starting point is in failing to assess the potential for risk in planning to deal with the risk and therefore in failing to train or equip to cope with
01:42:51 failing to train or equip to cope with such risks the London Fire Brigade is assisted and sets out by the London
01:43:03 assisted and sets out by the London safety plan to prove as approved and as yet
01:43:06 yet unamended on the 30th of March 2017 and it refers to the question of risk management setting out matters in this
01:43:18 management setting out matters in this way what does London Fire Brigade mean by risk it asks and it answers its own question the London Fire Brigades
01:43:30 question the London Fire Brigades understanding of risk is based on the likelihood of an incident occurring and its consequences
01:43:39 what the most likely incidents that may occur may be a fire in our house a flood a fire that does not breach
01:43:50 a fire that does not breach complementation and if you base your planning upon such level of risk you'll never have adequate resources capable and able of helping people in such a
01:44:01 and able of helping people in such a fire at the ground for town on the 27th of September of this year mr. Millard Queen's Counsel counsel to the inquiry [Music]
01:44:12 [Music] asked Commissioner Cotton whether there had been a structural or cultural failure by the lfb to respond to new hazards the response from the
01:44:25 hazards the response from the commissioner was to deny that there had been such a failure during the course of the commissioners evidence she stated that training about fires on building facades
01:44:36 facades would not have helped and I quote she said I truly don't think it would have benefited anyone to have more detailed knowledge about cladding to respond to the fire at Grenville because it
01:44:49 the fire at Grenville because it wouldn't have enabled them to extinguish the fire she said we suggest that it is imperative for the safety of Londoners that the lfb review their management of
01:45:01 that the lfb review their management of risk the consequences of not planning within an emergency service to deal with a known risk is precisely why the London
01:45:12 a known risk is precisely why the London Fire Brigade was outclassed by the Grenville tower fire without making sure that the London Fire Brigade has the resilience and resources to cope with a
01:45:23 resilience and resources to cope with a major disaster multiple FSG calls and a high population risk then we await the next disaster which will yet again lead to casualties and death without an
01:45:36 to casualties and death without an adequate response from the lfb but the truth from other submissions made today and from the background history from other fires is that far from the
01:45:49 other fires is that far from the Greenville tower being an unrealistic scenario the rest of a clan of a cladding fire wells well known to the lfb in 1999 after the Ghana
01:46:00 known to the lfb in 1999 after the Ghana cork fire the in Irvin the environment transport and regional affairs committee examined the potential of but sorry examined the potential risk of Bart
01:46:11 examined the potential risk of Bart spreading in buildings by external cladding systems this is 1999 the fire brigade union in their submissions
01:46:22 brigade union in their submissions observed that there are a number of risks posed by the use of combustible or badly installed external cladding systems and went on to make further submissions that the primary risk
01:46:34 submissions that the primary risk therefore of a cladding system is that it provides a vehicle for assisting uncontrolled fire spread at the outer face of the building with the strong
01:46:45 face of the building with the strong possibility of the fire re-entering the building at higher levels by windows or other
01:46:50 other unprotected areas in the face of the building this is in turn a threat to the life safety of the residents above the fire floor 1999 in her evidence
01:47:08 fire floor 1999 in her evidence commissioner cotton was asked this is on the 27th of September whether she'd been shown the lfb slide so that titled tall baling Sarek tall building facades
01:47:19 baling Sarek tall building facades grunts was no despite her background being the director of safety and assurance at the time whilst the circulation list contained her senior
01:47:31 circulation list contained her senior fire safety officers she did not know if any had actually seen the presentation she accepted eventually that the conclusions from the slide show
01:47:42 conclusions from the slide show demonstrated that there had been an emerging consciousness within the lfb that facades of high-risk buildings created risks of fire spread
01:47:55 now the key question is whether and how that information had been disseminated to frontline operational firefighters well we know repeatedly from the questions asked by counsel to the
01:48:06 questions asked by counsel to the inquiry that the answer from the frontline firefighters is they had no knowledge other than one or two who referred to it as having seen it themselves online or on television
01:48:22 the commissioners response to the document in relation to weather had the information had been given out to the operational firefighters she said this I don't think it has been because I wasn't
01:48:33 don't think it has been because I wasn't familiar with this document beforehand but the normal procedure would be if there was deemed to be something there was a risk that needed to be shared it will be developed into a training
01:48:44 will be developed into a training package that could be shared more widely asked if she after she knew why such a training package had not been undertaken no I don't asked why the presentation
01:48:56 no I don't asked why the presentation was only provided to a limited number of specialists and not been seen no idea it
01:49:07 specialists and not been seen no idea it was suggested by counsel to Akari that her evidence indicated both structural and cultural failings within the lfb a failure to more widely disseminate key elements of fire safety and her response
01:49:20 elements of fire safety and her response nobody would expect an incident like Grenville where the building would fail so spectacularly and be covered in such a highly flammable product and will be allowed to exist whilst ultimately
01:49:34 allowed to exist whilst ultimately accepting that the Grenville terrify it was not an edible risk and that the risk of such a far had been on the London Fire Brigades radar for at least nine months the Commissioner argued that
01:49:47 months the Commissioner argued that training would make no difference and of course we have the memorable part of the evidence from the Commissioner addressing the unrealistic scenario that had unfolded it greville Tara she put it where she
01:50:00 greville Tara she put it where she explained
01:50:01 explained I wouldn't develop a training package for a space shuttle to land in front of the shop
01:50:06 the shop and if we respond to it and deal with it in the same matter we do an incident of that scale I wouldn't expect us to be developing training or a response to something that
01:50:17 training or a response to something that simply shouldn't happen but does not the Commissioner understand that airplanes fly into towers concerts in large buildings are bombed and towers are
01:50:29 buildings are bombed and towers are vulnerable to fire but in her evidence we also learnt one further thing about
01:50:40 we also learnt one further thing about the tall building facades document she explained that the only reason she had looked at the tall building facades
01:50:51 looked at the tall building facades presentation is that she was going to be questioned before this inquiry asked by counsel for the inquiry have you studied this document since Grenville the tall
01:51:04 this document since Grenville the tall building facades one the Commissioner asked yes I've looked through it yes I've not studied it in detail I've looked through it who asked you to do that counsel to the inquiry asked well
01:51:16 that counsel to the inquiry asked well the answer for the Commissioner was once you've shown it here in this inquiry my natural curiosity led me to go and look at it natural curiosity forgive me if
01:51:32 at it natural curiosity forgive me if this seems judgmental commissioner but does this seem the right way for the London Fire Brigade Commissioner to be reviewing documents about cladding fire risk or is there something we are
01:51:44 risk or is there something we are missing we have the largest-ever civil disaster since World War two the largest call out of firefighters and appliances that anyone it seems has ever heard about and we have the deaths of 72
01:51:58 about and we have the deaths of 72 people from the vertical community that was the Grenville tower building but when does the Commissioner decide to
01:52:09 when does the Commissioner decide to look at documents that relate to high-rise blocks and cladding files
01:52:17 well it seems only when it is shown before this inquiry and we ask this question why did the Commissioner not say within hours if not days of the
01:52:28 say within hours if not days of the Grenville tower fire and I want to see everything the lfb has on high-rise plot Flyers and cladding fires why did she not say give me every piece of academic
01:52:40 not say give me every piece of academic research on cladding fires and let me understand what happened and see how we can improve the fact is that the Commissioner for the lfb did not ask for
01:52:51 Commissioner for the lfb did not ask for this material immediately the fact is that that defies belief why is the Commissioner of the London Fire Brigade not taking the lead in examining what
01:53:02 not taking the lead in examining what happened and why but it's worse than that because it also tells us that her senior management team did not brief us brief her forgive me on what was
01:53:14 brief her forgive me on what was available in the months leading up to the inquiry London has approximately 1600 high-rise blocks both residential and office the London Fire Brigade has
01:53:27 and office the London Fire Brigade has not trained to fight a compartment breaching fire in any of these blocks this cultural blindness to risk means that the very organization which we rely upon and pay for which we all believed
01:53:40 upon and pay for which we all believed before the ground fault out fire was in the business of disaster management and solution is quite incapable of dealing with a fire ground
01:53:51 incapable of dealing with a fire ground of this complexity this is like the Army and Navy saying we're pretty good at dealing with a minor skirmish but we have no plan and we've given no thought
01:54:02 have no plan and we've given no thought to fighting a battle because of the abject failure by the LFP to plan for this known risk no one single person was
01:54:14 this known risk no one single person was capable it seems of appreciating the growth of this disaster mr. Weatherbee as he examined the GRA 2014 and its contents and I only say this it is clear
01:54:27 contents and I only say this it is clear that the land of fire brigade has failed to comply with duty under gra 2014 therefore without such planning the fire type fighters
01:54:39 such planning the fire type fighters were left with inadequate equipment and no overall ability to make an assessment of all of the information available from FSG called nain nain nain calls from people at the scene
01:54:50 people at the scene CCTV photo graphs or other images sent down drone helicopter television air wave mobile phone or the handheld radios
01:55:03 wave mobile phone or the handheld radios nor was there the equipment available which might have supported communications such as the vector computer-based simulation system described by SM Johnson as not working
01:55:15 described by SM Johnson as not working for 9 years or the other not working or useless equipment structure such as a Stryker camera tough books mesh nodes and CSS the FSG call centers were blind
01:55:30 and CSS the FSG call centers were blind to the events at the fire ground and the command units didn't have reports from the fire fighters within the block and no way to bring together an assessment
01:55:41 no way to bring together an assessment of the FSG information so no wonder we have the discrepancy in time and the communication of the abandonment of stay
01:55:52 communication of the abandonment of stay put
01:55:54 put because there were no information feeds and no real communications we in fact have two separate determinations that the stay-put policy should be changed to
01:56:05 the stay-put policy should be changed to an evacuation on the 26th of september in the questions asked by counsel to the inquiry of AC and ero he was asked about
01:56:17 inquiry of AC and ero he was asked about his decision to abandon stay put and two important pieces of information arose first mr. rose ignorance as to
01:56:28 arose first mr. rose ignorance as to watch manager Johnson's pilot exercise which had demonstrated the operational difficulties which arose once far so I will guidance calls numbers rose above
01:56:39 will guidance calls numbers rose above seven
01:56:41 seven second that whilst mr. Roe had abandoned the state of policy as of 247 in fact by 235 Joe Smith within one of
01:56:57 in fact by 235 Joe Smith within one of the FSG centers was advising that callers evacuate get out this could be the last chance now how is it that we
01:57:08 the last chance now how is it that we have a situation where the call center assessment without sight of the tower on fire is that stay put has to be abandoned yet that this has
01:57:20 has to be abandoned yet that this has not managed to communicate itself to mr. Lachlan who had been in charge at that time and therefore not onwards to mr. Roe wouldn't lives have been saved if
01:57:32 Roe wouldn't lives have been saved if someone in a command position to make the call to abandon stay put could have had an understanding of the volume and factual content of the FSG calls as well
01:57:43 factual content of the FSG calls as well as effective communications with firefighters in the tower class site of the tower
01:57:52 Marcia Gomez put it this way the decisions all better yet the lack of decisions at the time cost lives and I
01:58:04 decisions at the time cost lives and I truly believe that a lot more lives would be saved if things were done quicker it becomes obvious that we're a 21st century emergency service is
01:58:17 21st century emergency service is reliant on raid on runners with pieces of paper that this is fit only to just about on occasions convey emergency
01:58:28 about on occasions convey emergency rescue information but as regards the equally important need to use that information to assess the situation it is simply not fit for purpose
01:58:44 I'm going to move on to the radios and the problems with those at the tower the handheld radios used by the firefighters
01:58:55 handheld radios used by the firefighters at the ground fault our fire operated on a most powerful signal gets through line-of-sight principle which means that a standard high-rise building with an
01:59:07 a standard high-rise building with an inevitable iron steel structure reinforced concrete components will block radio waves attempted by communication to me made up and down the
01:59:19 communication to me made up and down the tower the limitations of that equipment used resulted in very significant failings on the night you will recall
01:59:32 failings on the night you will recall the evidence of firefighter Oberg one of the first firefighters to arrive mr. a burn witness fires witness flats on fire one and two levels above the
01:59:46 on fire one and two levels above the flower he spoke to individuals coming from flowers and he also noted heavy smoked heavy smoke logging in flats on the sixth floor and he attempted to
01:59:57 the sixth floor and he attempted to radio mr. doubter using his hand out radio and he heard nothing back he said this I radio down to mr. doubt using my handheld ready and said something along
02:00:09 handheld ready and said something along the lines of the flat above the far floor is on fire their kitchen is alight we need a be a crew and breaking in gear
02:00:20 we need a be a crew and breaking in gear I only radioed once I don't remember hearing any other radio traffic at that time I didn't get a reply but I believed my message had been transmitted and that
02:00:31 my message had been transmitted and that I had spoken clearly again once on the sixth floor i radioed down to the governor mr dout again but I didn't get any reply I didn't get a reply to any of
02:00:44 any reply I didn't get a reply to any of the radio messages I sent to the governor but I assumed he was still very busy but that he could still hear me but was this vital evidence for mr. Oberg who is the individual that had decided
02:00:55 who is the individual that had decided that it would be a good idea to go up the stairs of the tower and see how matters were progressing was that vital information received and acted upon or understood at
02:01:06 received and acted upon or understood at these early stages mr. Darden's evidence in this regard was given on the 27th of June of this year and he said that he
02:01:20 June of this year and he said that he received no information from mr. Oberg as to what mr. Bern Bern was discovering concerning the conditions on the floors above the fourth floor the evidence for
02:01:33 above the fourth floor the evidence for a mr. Berlin and mr. Dunn is entirely compatible mr. Ober no calls trying to transmit the messages but received no acknowledgement or reply mr. Dowden does
02:01:46 acknowledgement or reply mr. Dowden does not recall getting these messages and given that we know where he was standing which was close to the base of the tower it is likely that he simply didn't receive the radio traffic as the tower
02:01:58 receive the radio traffic as the tower structure itself would have been blocking the radio transmission if these
02:02:09 blocking the radio transmission if these calls had been made by a mobile phone as was demonstrated by the harrying long hall yet another testament to courage and bravery by marcia gomez as he spoke
02:02:22 and bravery by marcia gomez as he spoke to miss Foxx at the call center then in all likelihood the call-in information to mr. Dowden would have got through now
02:02:34 to mr. Dowden would have got through now the ability to use a mobile telephone in fire conditions without question is difficult and it requires an individual phone call to be made the point is that
02:02:46 phone call to be made the point is that type of technology will allow a call to be made in and out of a tower it may be that you can't just or should not rely upon your personal mobile phones but the
02:02:57 upon your personal mobile phones but the technology is there perhaps it's obvious that communications are vital but let's remind ourselves of some more of the
02:03:08 remind ourselves of some more of the evidence
02:03:09 evidence miss DaSilva at the bridgehead the sheer volume of FSG calls coming in mentors receiving information by small pieces of paper runners and also by radio adjusts
02:03:21 paper runners and also by radio adjusts the floors and flat numbers the calls the volume of FSG calls were very high she went on to say another problem was the BA crews normally used channel 6 to communicate with entry control
02:03:33 communicate with entry control however this channel was proving difficult throughout the incident there was so much feedback on the channel that it was difficult to use someone tried to layer a repeater on the ground floor bridgehead which is a kind
02:03:46 ground floor bridgehead which is a kind of booster to help with a signal but that didn't help at all I've never experienced communication problems on that scale before and she went on the BA channel wasn't working well so what was
02:03:58 channel wasn't working well so what was he effect of that she said crews couldn't tell me what they had or hadn't done through that means either some were
02:04:09 done through that means either some were committed to a specific FSG but before they got there they came across casualties who they needed to help there and then in her evidence on the 25th of July again asked about communications so
02:04:26 July again asked about communications so for a lot of the time we're unable to get any communications from them at all that's the firefighters which is worrying in terms of safety because we want to monitor their air we want to
02:04:39 want to monitor their air we want to know their location if they get into trouble we need to know where to send an emergency crew as well as well as where they are firefighting where they think
02:04:50 they are firefighting where they think they are where they are finding casualties what rescues are taking place we are not able to get any of that information back either firefighter
02:05:03 information back either firefighter Morrison Amanda Morrison she put it this way for me the comms is a massive issue as a game changer for that job not
02:05:14 as a game changer for that job not having comms is a bit like being disabled in the job you can't talk to each other you can't tell each other what you need you're trying to grab people's helmets
02:05:25 you're trying to grab people's helmets and talk to each other through our sets you can't talk to downstairs to see if they've got anyone coming up whether they got any news on us getting water
02:05:36 firefighter foster Katie foster I
02:05:41 attempted to use my radio to pass on the information that we had found and especially as there were residents inside and in fact she had a colleague come across a mail that told us that
02:05:54 come across a mail that told us that were five people inside a flat she remembered trying to radio through around seven times but was unsuccessful Greg the partner she was with also tried
02:06:06 Greg the partner she was with also tried but was also unsuccessful now all of this evidence all of this evidence was given before the Commissioner gave her evidence do they not have someone within
02:06:20 evidence do they not have someone within the London Fire Brigade that might have been tasked with listening to what was being said before this inquiry how can the Commissioner say that she wouldn't have changed a thing floor 14 we suggest
02:06:35 have changed a thing floor 14 we suggest is a demonstration of these communications problems leading to loss of life the inability of firefighters to communicate to communicate within the
02:06:46 communicate to communicate within the tower both amongst themselves and with the bridgehead led amongst other things to the tragic failure to rescue occupants of flat one 1-3 Omar al Haj
02:06:58 occupants of flat one 1-3 Omar al Haj Ali Dennis Murphy Donna Dean and Jeremiah Dean firefighters Cornelius Marion Murphy and Saunders were the
02:07:09 Marion Murphy and Saunders were the first crew to visit floor 14 they were unable to notify anyone by radio after the number of residents in flat one one three and the need for additional crew crews to rescue them with secondary be a
02:07:21 crews to rescue them with secondary be a kiss it was only on return to the bridgehead that firefighter Cornelius was able to convey that information back at the bridgehead I informed him we
02:07:32 at the bridgehead I informed him we needed more be a set wearer's and more people to go up there and rescue the eight people
02:07:42 he added I tried constantly to contact the bridgehead anyone downstairs telling them we needed second sets and what we had found and that we weren't going to be able to bring the people down the
02:07:53 be able to bring the people down the stairs and that was on both of his radios firefighter Murphy tried as well but at that point at no point did we hear anything we didn't hear any chatter
02:08:04 hear anything we didn't hear any chatter over the radios at all we tried again there was no ready communications with the Bary sector with our hand tells says firefighter Cornelius firefighters
02:08:16 firefighter Cornelius firefighters Herrera and firefighter orchard ultimately affected a rescue of only four of the eight residents from flat one one three firefighter Herrera recollects being tasked to rescue three
02:08:28 recollects being tasked to rescue three people five had to orchard to rescue six firefighter Herrera said he was tasked but for a family an adult male Pema and child firefighter orchard she called us
02:08:41 child firefighter orchard she called us forward and told us that our I think she said six people in flat one one three on level 14 she said they're all right but they're not all right now we need to get them out now we know that firefighter
02:08:55 them out now we know that firefighter Eric intends that both he was told this is his evidence by omar al hajjali that there were no more occupants in the flat that whilst he converse to mr. ali in the lounge of flat 1/3 he mr. Herrera
02:09:09 the lounge of flat 1/3 he mr. Herrera states who is not aware of the residents in the first bedroom the credibility of those assertions are strongly challenged and the correct chair is invited to
02:09:20 and the correct chair is invited to determine this matter notwithstanding those issues it is plain that the inability of firefighters our air and orchard to communicate with the bridge
02:09:31 orchard to communicate with the bridge yet denied them the opportunity to confirm the expected numbers of persons in the flat
02:09:41 firefighter Cornelius ask the question one question that's arisen is what difference would radio contact made for you at that stage for me it was a big
02:09:53 you at that stage for me it was a big factor it would have given me confidence in what I was telling the people that we could send another crew of firefighters up or more crews multiple crews we're second sense that to me would have been
02:10:05 second sense that to me would have been a key element in saving them the fire officers association submission set out by mr. Broun Queen's counselor mr. wall dated the 6th of December 2018
02:10:19 dated the 6th of December 2018 understandably observe at paragraph 103 that communication problems were one of the factors impacting upon ability to undertake an evacuation since it meant
02:10:30 undertake an evacuation since it meant that crews could not communicate how many BA were required for a particular floor or we suggest that's right but an understatement of the position since the
02:10:42 understatement of the position since the fire where we got to the absence of suspensive change following these incident gives rise to concerns that the same will happen post Grenville and has
02:10:56 same will happen post Grenville and has the communication equipment failure in address in safar sadly we suggest that the LF B's response has been piecemeal at best so you'll have noted our
02:11:10 at best so you'll have noted our submissions in this regard at pages 24 and 25 of the written submissions the London Fire Brigades 24th of October 2018 updated position statement in other
02:11:21 2018 updated position statement in other words updating what they've done since a fire title actions since the ground fault our document made reference to some steps to address some of the communication issues identified
02:11:34 communication issues identified reference made the as an example the introduction of improved bury equipment to be undertaken they're referred to but not until 2024 21 also referring to the
02:11:47 not until 2024 21 also referring to the command unit replacement project acknowledging the ongoing issues regarding the live regard the reliability of the CSS is still over two years from completion
02:11:58 two years from completion now of course such step as those are welcome but notable admissions include the failure to address the following a
02:12:09 the failure to address the following a the problems of communicating using the existing handheld radio system within a concrete steel and glass building and at incidents where there is a significant
02:12:21 incidents where there is a significant volume of radio traffic B the apparent lack of effectiveness of the repeater and/or leaky feeder equipment see the
02:12:34 and/or leaky feeder equipment see the need for realistic training to overcome communications in what are known to be challenging circumstances d the failure
02:12:45 challenging circumstances d the failure to instruct an expert in the field of communications to overcome problematic communication within buildings and built environments E the need for funding and
02:13:00 environments E the need for funding and policy change to enable the deployment of airway farling radios directly on the far ground this piecemeal approach
02:13:11 far ground this piecemeal approach undertaken at a glacial pace is typify by the fact that the London Fire Brigades written closing submissions simply state that the brigade is aware
02:13:22 simply state that the brigade is aware of a range of incident communication challenges both in relation to the fire ground radio and the breathing abrasive operation cooks are operators of equipment and capacity that occurred at ground fault our going on to say in
02:13:36 ground fault our going on to say in respect to the brigades fire ground and be a radio equipment provision both systems are scheduled for replacement in the financial year 2019 20 moving on the
02:13:48 the financial year 2019 20 moving on the LF B their sets out the lessons learned an experience from the ground fault our fire will be considered as part of the development of the technical specification for these replacement
02:13:59 specification for these replacement radio projects
02:14:02 so instead of setting out in detail for this inquiry what the lfb has done and proposes we are left to look through their announcements the London Fire
02:14:13 their announcements the London Fire Brigade document titled replacement of incident ground communications update dated the 21st of May 2018 sets out in a frankly a confused document a decision
02:14:24 frankly a confused document a decision that has been named to consider the purchase of radio sets and it looks like the purchases from a company called Intel the cost assessment being 1.6
02:14:36 Intel the cost assessment being 1.6 million but if that is what the London Fire Brigade is setting itself out as needing to do as we understand it the problem is that such radios from Intel
02:14:47 problem is that such radios from Intel will be simplex only simplex meaning that only one person can talk at a time this means that even if a firefighter is communicating a relatively routine
02:14:58 communicating a relatively routine message so long as this is more powerful this will block the communication from another firefighter on the same Channel all cut out that call the person with
02:15:09 all cut out that call the person with the strongest signal will generally be the person closest to the reason the receiver radio or with the least obstructions and radius of this time are also low powered and therefore signals will be easily
02:15:21 and therefore signals will be easily obstructed by reinforced concrete so we doubt whether the lfp is on the right track as these types of handheld radios
02:15:34 track as these types of handheld radios will not penetrate a building such as a creme fall tower itself the issue is not just whether there was too much radio traffic but whether communications can
02:15:46 traffic but whether communications can be established up and down a building we know a radio that is contained within a mobile telephone as demonstrated by
02:15:57 mobile telephone as demonstrated by Marcia Gomez will call up and down a tower and that is because it is transmitting a signal outside of the tower to a cell site mast and then back to a recipient a radio can transmit a
02:16:11 to a recipient a radio can transmit a simple radio consume it to an outside signal
02:16:15 signal Peter and then back into the building as long as they are line of sight one to another the New York system could be adopted which allows for a hardwired it's called an arc system which could be
02:16:27 it's called an arc system which could be installed in high-rise buildings that allows their in to floor communications
02:16:35 the London Fire Brigade and this inquiry need to have the assistant assistance of a communications expert to vies us what the best solution is to these types of
02:16:46 the best solution is to these types of communications issues within a fire ground in a large building in summary the ability to communicate receive and process information with the London Front within the London Fire Brigade
02:16:57 Front within the London Fire Brigade structure was appalling the firefighters response to the fire and overall attitude was a commendable keep going regardless but it was undermined by the inability to pass
02:17:10 undermined by the inability to pass communications from firefighter to firefighter and firefighters to decision-makers the reaction from the fire plaintiff RBA has been far too slow
02:17:23 fire plaintiff RBA has been far too slow and we suggest that the LF B's leadership remains incapable of making decisions that adequately react to the dangers faced by the people under its care so if I may I would suggest I have
02:17:38 care so if I may I would suggest I have another 10 minutes yeah you keep going if you're content I am so let me move on to then the views of people from the tower regarding equipment failures because some have addressed this
02:17:51 because some have addressed this rosemary oil Wally 15th of October
02:18:00 she says I would like to say that we lost beautiful beautiful people that night innocent children everyone that passed away that night was innocent and
02:18:12 passed away that night was innocent and nobody deserved that if events might have played out differently than I probably wouldn't be sitting here today myself so I just think the people that
02:18:23 myself so I just think the people that came back that night or the firemen that came back that night they were you know on many occasions people came back people had the chance to see how many people were brought into our flat people had the chance to see the state of the
02:18:35 had the chance to see the state of the people that brought into our flat and for there not to be any precautions taken into place and you know the right equipment being given to people to come and get people out of our flat I think
02:18:46 and get people out of our flat I think if they did have the correct equipment then I personally think that the people that passed away in our flat possibly wouldn't have passed away and that's all
02:18:57 wouldn't have passed away and that's all I'd like to say had in Kumasi Co 6 November we've seen failings and failings
02:19:07 failings I've been failed so many times you know failings and failings and failings with other files and other lessons not learnt so Grenville has to stand for something and it's to stop here about how people
02:19:19 and it's to stop here about how people are treated and how the loopholes in the system need to be closed you know justice for me is that you know this never happens again you know we have a fair system we have a lot to deal with
02:19:31 fair system we have a lot to deal with especially in this environment at the moment but it has to stop here the London Fire Brigade needs a shake-up from the top down the Grenville tower
02:19:44 from the top down the Grenville tower fire marks a point in history where the brigade should have said we need to change we need to review our resources to be able to undertake realistic planning but what were known risks to
02:19:56 planning but what were known risks to high-rise towers prompt cladding fires we do not see that the Commissioner or her office have recognized this need to change within days if not weeks of this
02:20:08 change within days if not weeks of this fire that under fire brigade should have been calling for a radical chain two resources and a dedicated discussion with the mayor's office and the Cabinet Office regarding funding to cope with
02:20:19 Office regarding funding to cope with major disasters that discussion should have been directed at the question what value do we place on the lives of our citizens and how far are we prepared to
02:20:33 citizens and how far are we prepared to pay for the protection of our people in essence that is the same discussion which lies at the heart of this inquiry and we will be examining in phase two
02:20:44 and we will be examining in phase two the question there as we continue into phase two is what price are we prepared to pay as a society to protect our own people from commercial greed local
02:20:56 people from commercial greed local authority cost-cutting and institutional apathy unless we change our approach to the assessment of risk and include
02:21:07 the assessment of risk and include within that risk assessment the very people who will suffer the risk when we come to the question of the expenditure of resources on equipment and training
02:21:20 of resources on equipment and training within such organizations as the lfb then no doubt we will be here again at some point in the future confronting these same issues the families we
02:21:33 these same issues the families we represent say stop and change on their behalf we say stop and change no more fires that the LFP cannot deal with fund the emergency services properly and have
02:21:44 the emergency services properly and have leaders of these services in place that can exercise leadership not denial so those are our submissions good well thank you very much mr. Steen have you
02:21:55 thank you very much mr. Steen have you done very well to finish by a plus four Thanks thank you very much well that's obviously a good point to finish for today so we'll break in just a moment and we resume tomorrow with some more
02:22:08 and we resume tomorrow with some more closing statements according to my running order this would be named for mr. Menon first thing morning good look thank you all very much
02:22:20 thank you all very much ten o'clock tomorrow please