Phase 1 closing statements from multiple core participants including TMO, Fire Brigades Union, and Fire Officers Association regarding building failures, fire safety systems, and emergency response.
00:12:22 you
00:12:50 good morning everyone welcome to today's hearing in a moment I'm going to invite miss Jarrett to make a closing statement on behalf of the TMF but before that I
00:13:01 on behalf of the TMF but before that I think mr. millet has something he wishes to say yes mr. chairman thank you and I just wanted to make it clear that there will be a shortening of today's timetable for this reason both PSB and Ryden have indicated to us at the end of
00:13:15 Ryden have indicated to us at the end of yesterday and overnight that they do not now wish to make oral submissions so they leave us only with their written closings we'll have to arrange the timetable a little bit around that yes
00:13:26 timetable a little bit around that yes well thank you for letting us male name is Jared invite you to make your statement on behalf of the tiller thank you thank you thank you sir for giving
00:13:39 you thank you thank you sir for giving us this opportunity to address you on the evidence that has formed part of phase one we hope that what we say will be both appropriate and helpful to you at this stage the evidence we have heard
00:13:50 at this stage the evidence we have heard from the bereaved survivors and residents and from the men and women who attended on the night of the fire to try and save lives has been humbling we have heard the accounts of those who have
00:14:01 heard the accounts of those who have lost so much but have all attended to give their evidence with such dignity and clarity their evidence is invaluable it is also wanting this evidence and the
00:14:13 it is also wanting this evidence and the evidence of firefighters must be vital in helping the inquiry understand how fire and smoke spread but also crucially to understand why so many did not
00:14:25 to understand why so many did not evacuate and as a consequence lost their lives
00:14:29 lives the TMO now no longer has a role in managing housing stock and delivering services and it no longer employs a workforce to carry out these functions however it will remain in existence
00:14:40 however it will remain in existence until the public inquiry and other relevant legal processes are completed it continues to fully support the ongoing work of the inquiry and the TMO
00:14:51 ongoing work of the inquiry and the TMO encourages you sir to make findings where you are able to at this stage we recognize that this will be with a view to making important recommendations however
00:15:03 however due to the short timeframe in which extensive evidence has been produced and heard the forensic investigations that are still outstanding and the extent to which experts have repeatedly referred
00:15:14 which experts have repeatedly referred to their conclusions has been provisional the scope of your findings will necessarily have to be limited at this stage but there are important findings to be made as well as
00:15:26 findings to be made as well as establishing the factual narrative of what happened on the night we hope you will consider how the fire started and how it spread across the envelope of the building in respect of the evidence you
00:15:38 building in respect of the evidence you have heard and in addition to our written submissions we wish to make all submissions on four topics one the building envelope dr. Lane professor
00:15:49 building envelope dr. Lane professor torero and professor Bisbee all conclude that the uPVC windows surrounds provided a route for the spread of fire into the external side of the build the building and the combustible materials that made
00:16:02 and the combustible materials that made up the cladding system on the exterior of the tower was then responsible for the spread of fire which rapidly took hold of the building multiple catastrophic fire spread routes were created by the cladding materials but
00:16:15 created by the cladding materials but also the construction detailing such as the 14 columns around the building and the architectural crown unchallenged by effective cavity barriers they provided direct pathways for flame spread both
00:16:28 direct pathways for flame spread both vertically and horizontally around the building the experts have also concluded that those composite materials used did in fact propagate the spread of fire this is a complex topic
00:16:39 this is a complex topic however the experts are unanimous ultimately the combination of materials that encase the building was the key proponent in the spread of fire we
00:16:50 proponent in the spread of fire we encourage you to make factual findings and respect the materials that were used and how the fire spread across the envelope of the building the use and composition of these materials had been
00:17:01 composition of these materials had been contemplated since the beginning of the refurbishment project in 2012 and was visible and seen by a whole range of technical and professional bodies
00:17:12 technical and professional bodies including those with specific responsibilities for Building Control and fire safety an important outcome of this inquiry must be to prevent this
00:17:23 this inquiry must be to prevent this composition materials been erected or maintained on high-rise buildings to ensure that a fire of this scale and devastation never happens again with the
00:17:35 devastation never happens again with the consideration of recommendations at the end of phase one of the inquiry we do hope that significant steps will be taken to achieve this and we note the ongoing work of the ministry of housing communities and local government in pursuit of this to the active and
00:17:49 pursuit of this to the active and passive fire safety features the failure of the materials cloud on the outside of Grenville tower to resist the spread of flame undermines the entire fire safety
00:18:00 flame undermines the entire fire safety strategy multiple active and passive fire safety measures were in place at Grenville tower as is set out in table 2.3 of dr. lanes report there is no
00:18:12 2.3 of dr. lanes report there is no provision or statutory guidance for the number or combination of active or passive safety systems that must be in place for any one single construction a
00:18:23 place for any one single construction a Grenville tower dr. Lane has identified 16 different passive systems and 11 different active systems that were in city 27 different measures in total
00:18:34 city 27 different measures in total designed to operate independently but in concert or layers to provide protection in the event of a fire the majority of these systems were formed as part of the
00:18:45 these systems were formed as part of the original build and some have been modified or updated over time including as part of the building refurbishment programme from 2012 to 2016 Professor
00:18:57 programme from 2012 to 2016 Professor torero stated at the backbone of the fire safety strategy is the concept of no spread of fire and no external spread of fire dr. Lane qualified the strategy
00:19:08 of fire dr. Lane qualified the strategy by stating once the fire broke into the rain screen system the remaining active and passive fire protection method measures within the tower were then required to perform during an
00:19:19 required to perform during an extraordinary event according to Professor torero it is at 105 in the morning that he attributes
00:19:30 morning that he attributes mentation is failing therefore from the point of the start of the fire 54 minutes past midnight until 1:05 a.m. some 12 minutes in total that is the
00:19:41 some 12 minutes in total that is the period of time that represents the building operating as designed dr. Lane in her evidence was not prepared to attribute the failure of compartment ation and taught 1:13 a.m. this being
00:19:52 ation and taught 1:13 a.m. this being the point at which flames had not only breached the window flat 16 but had begun to impinge on level 5 above however dr. Lane confirmed during questioning that she saw evidence of
00:20:04 questioning that she saw evidence of fire being inside the cladding as early as 108 a.m. and that once it was inside the cavity the spread of fire was inevitable on any analysis this is a
00:20:17 inevitable on any analysis this is a short period of time in which to consider the fire system's efficacy and the effect of compliance on performance it is against this background in due course these safety systems including
00:20:28 course these safety systems including systems such as the stairs and the flat doors the lifts the smoke ventilation systems and the risers must be properly assessed would you not rehearse our own
00:20:39 assessed would you not rehearse our own written submissions and the submissions of many of the core participants on these specific fire safety features here save to agree that they are not matters that the experts have yet concluded on and therefore will necessary form part
00:20:51 and therefore will necessary form part of phase 2 along with the assessment of the spread of fire and smoke within the building 3 evacuation the performance of
00:21:03 building 3 evacuation the performance of the single stairs on the night will of course be examined in more detail of phase 2 but it is significant that it managed to continue supporting evacuations and firefighting activities
00:21:14 evacuations and firefighting activities throughout the life of the fire professor person made the calculation that it had taken that it could have taken forgive me 7 minutes to simultaneously evacuate 293 persons from
00:21:25 simultaneously evacuate 293 persons from the tower now notwithstanding the issues are communicating any such decision to evacuate and the particular concerns of course in relation to vulnerable persons the inquiry will want to consider that
00:21:37 the inquiry will want to consider that the stairs at Grenville tower could have coped with a full building evacuation and to what extent that is relevant to the LF B's decision-making and saving life on the night for the
00:21:52 and saving life on the night for the involvement of the TMO and the RB KC's Lalo's on the night if you are minded to make findings in relations TMA's
00:22:03 make findings in relations TMA's involvement on the night we invite you to consider the following on the 15th and the 16th of November the inquiry heard evidence from the two local authority liaison officers the Lalo's Nicholas Layton and my crumble employees
00:22:16 Nicholas Layton and my crumble employees of our bkc they attended the incidence of Rep census of the borough and you also heard from the four of the TMO staff who were in attendance
00:22:28 staff who were in attendance Nicholas Layton was the first to arrive at o2 47 a.m. and he immediately determined this was a level three major incident he contacted David carry the emergency planning manager RB Casey and
00:22:40 emergency planning manager RB Casey and the RB Casey contingency management plan the CMP was activated and the Beck the borough emergency command center which manages requests for resources were set up in these circumstances the TMAO
00:22:53 up in these circumstances the TMAO emergency plan was was properly not put into operation because it had been superseded by the borough's CMP it would have been inappropriate to have separate
00:23:05 have been inappropriate to have separate and different plans in operation at the same time as a consequence the TMO had no formally defined role in the sponsors the emergency the employees of the TMA that attended on the night did so
00:23:17 that attended on the night did so voluntarily and to offer assistance in whatever capacity they could the TMO did understand as did the lay low Nick Layton that they would have a role in
00:23:28 Layton that they would have a role in assisting were dealing with displaced residents in the wake of the incident and to assist our bkc and the Red Cross with managing rest centers once they have been set up by the borough
00:23:41 have been set up by the borough mr. Layton stated when he first spoke to mr. black that he told him that we are setting at rest centers and that he needed to get the staff there to assist and that was the only top
00:23:52 and that was the only top that was discussed with mr. black and lights there were two specific requests firstly the list of residents or survivors and secondly that of plans
00:24:03 survivors and secondly that of plans firstly the list of residents or survivors the inquiry heard from Theresa brown the tas director of housing she'd mobilized her team star from the TMO who
00:24:15 mobilized her team star from the TMO who assisted in running the rest centers 41 staff members attended in total to support the rest centers she took the decision herself to organize a system at the rest centers to record a list of survivors and those
00:24:27 record a list of survivors and those missing in order to try and assist the LF B's rescue operation neither the lfb nor any other organization requested her to do this and staff were instructed to
00:24:38 to do this and staff were instructed to record him writing the names addresses and household information of persons both safe and missing this information was then passed back to her - Razer Brown who passed it directly to the LF B
00:24:49 Brown who passed it directly to the LF B via the command unit clearly this information was never going to provide a complete record as not all these survivors attended the designated rest centers that have been set up these
00:25:01 centers that have been set up these documents were also not put to firefighters and there has not been any exploration of the use if any that was made of this information by the LF b the
00:25:12 made of this information by the LF b the first recorded request for information regarding residents is made to the lay low my crumble at the 4th tactical command meeting the TCM at 10 minutes past 7:00 in the morning he was
00:25:25 minutes past 7:00 in the morning he was asked to provide a copy of the Electoral Register of course this is something that the RV case RB Casey would have had and was not in the teemo's possession TMO staff did not attend any of these
00:25:36 TMO staff did not attend any of these meetings they were not invited to teresa cam brown confirmed that she was not asked and did not forward any list of residents to the LF b and an answer to
00:25:47 residents to the LF b and an answer to rigorous questions by council to the inquiry she stated that these lists were of limited use she said this because this is de Civ in our system for who is
00:25:58 this is de Civ in our system for who is our tenant at a moment in time which I believe is as up-to-date as possible but it wasn't giving as information about who was actually there on the night and who was safe and who was missing I was concentrating on that
00:26:11 was missing I was concentrating on that information from the rest centers because that was in a sense more helpful than relying on data that isn't really telling you if someone is in a building on the night the point being the list of
00:26:23 on the night the point being the list of registered tenants would have been of limited value to firefighters as it did not represent of course he was actually inside the building on the night plans
00:26:34 inside the building on the night plans mr. Layton's evidence was that he had no recollection have been asked for plans prior to his departure at 7:00 a.m. he stated in evidence that if the NFB have been asking for plans they had not made
00:26:46 been asking for plans they had not made those requests to him if they had he said they weren't made to me there is no record for any requests for plans in either the first the second all the third TCM meetings according to the
00:26:58 third TCM meetings according to the Rollag at 4:53 in the morning there is the first note in the log in relation to plans stating Cu staff report building plans should be in fire box in Lobby
00:27:11 plans should be in fire box in Lobby suggesting there have been no previous attempts to locate them there was not in fact two premises information box a Grenville tower and we heard Assistant Commissioner ro giving evidence that he would not necessarily expect expected
00:27:23 would not necessarily expect expected there to be a premises information box in a high-rise building this was information that was recorded on the operational response database the ORD
00:27:34 operational response database the ORD the ORD was however and as we've heard over the course of the last few days incomplete plans that have been previously surprised to the lfb had not been stored on the ORD the north
00:27:48 been stored on the ORD the north kensington fire station attended ground fault our regularly to carry out familiarization visits and the TMA were proactive in facilitating these visits the lfb station diary shows that nine
00:27:59 the lfb station diary shows that nine visits were carried out in 2016 or they're apparently not recording a further 10th visit in July 2016 that watch manager doubt and attended with his watch specifically to familiarize themselves with the building after the
00:28:12 themselves with the building after the refurbishment works were completed and a further six visits were recorded in 2017 prior to the fire at OSA 613 in the Rollag there
00:28:23 the fire at OSA 613 in the Rollag there is a note will attempt to locate plans this is in fact the first direct evidence that a request for plans will be made mr. black confirmed in evidence on more than one occasion that he has no
00:28:36 on more than one occasion that he has no recollection have been asked for plans there is no contemporaneous note of him being asked to provide any plans he did however provide plans to rbk seen in email sent directly to the dangerous
00:28:48 email sent directly to the dangerous structure engineer john allen the inquiry has not had evidence from mr. Allen but we know that he was in attendance to a strike to assess the structural integrity of the building it
00:28:59 structural integrity of the building it appears from TMA's investigation this email was forwarded to mr. Allen by mr. black at o 616 some two minutes after it was received by him at oh six 14 the
00:29:11 was received by him at oh six 14 the assortment of emails has been produced by the inquiry show a number of discrepancies were time TMO have assisted the inquiry by highlighting where emails are likely likely to record
00:29:22 where emails are likely likely to record timings inaccurately and have sought the assistance of their specialist IT facilitator itg in doing this and this information has been provided to your inquiry team sir you may feel that the timing is when certain
00:29:34 may feel that the timing is when certain emails were sent or forwarded between recipients at this time is not a matter you need to make specific findings on whether or not detail plans of the building were provided after a request
00:29:45 building were provided after a request as late as oh six thirteen you may think is not of great significance to the firefighting and rescue operation by this time we know that firefighters had already acquired the basic floor dita
00:29:57 already acquired the basic floor dita the basics details excuse me the basic details of floor and flap layout inside the tower which is what they would have required from any plans that have been provided however if this
00:30:10 that have been provided however if this is required you will need to examine the material that we have provided your inquiry have also notified us that a peep
00:30:18 peep it's document provider is investigating this information and we'll report back on the matter in due course you will need to consider these forensic investigations before making findings of fact on these issues
00:30:31 making findings of fact on these issues it appears also that the inquiry has not been provided with any emails from the lfb that deal with correspondence to firefighter Thomas Goodell identified as the lfb single point of contact for
00:30:42 the lfb single point of contact for emails between lfb staff and council representatives on the night of the fire to razor Brown has identified two other firefighters with whom she had contact
00:30:53 firefighters with whom she had contact on the night that could be explored if it is concluded that further details are needed to establish this timeline of communications for these reasons we submit that it would not be safe to make findings and respect of any specific
00:31:04 findings and respect of any specific times that information may have been provided at this stage the TMO sir will continue to support and fully engage with the work of the inquiries that now
00:31:16 with the work of the inquiries that now approaches phase two how and where the smoke spread once it came back inside the building along with the compliance of the active and passive fire measures are matters that you will wish to
00:31:27 are matters that you will wish to consider in greater detail at phase two however sir we support you making findings now at the close of phase one in relation to the issues of how the
00:31:39 in relation to the issues of how the fire started where the fire started and how it spread from its seat to the exterior of the building together with the fire and rescue effort efforts and
00:31:50 the fire and rescue effort efforts and the evacuations on the night this is in the hope that recommendations can be made the may be of importance to the safety of residents now living in high-rise accommodation around the
00:32:04 perfect thank you very much [Music]
00:32:13 now next I'm going to invite mr. seaward to make a closing statement on behalf of the FB you take your time mr. seaward lips I'm not gonna rise while you get
00:32:25 lips I'm not gonna rise while you get organized
00:32:50 you wanna do it thank you well the FPU continues to support and encourage a
00:33:01 continues to support and encourage a full and open inquiry the bereaved the survivors and relatives of the deceased the BS ARS need to learn as much as possible about the facts surrounding the deaths of their 72 loved ones and this
00:33:14 deaths of their 72 loved ones and this inquiry should be a turning point in fire safety and in the provision of fire and rescue services occupants of high-rise residential buildings should not have to fear the risk of fire but
00:33:25 not have to fear the risk of fire but should be reassured that a layered approach to fire safety providing defense-in-depth has bananas being applied and enforced to their homes likewise fire fighters and control room operators should never again be put in
00:33:38 operators should never again be put in what we say is an impossible position such as faced them on the night the construction industry government departments and the fire service nationally and locally all need to learn the right lessons from the tragedy these
00:33:50 the right lessons from the tragedy these are needed both to improve our national fire safety regime and to provide the operational procedures training and resources which are needed for an effective emergency response that recognizes both the fact that far is
00:34:01 recognizes both the fact that far is unpredictable and the risk the compartment ation might be breached meanwhile the firefighters and control room staff who worked in appalling conditions on the 14th of June need
00:34:12 conditions on the 14th of June need protection from unwarranted criticism firefighters were not aware that the building envelope of Grenville tower was rainscreen cladding little ended it was combustible all the - created multiple catastrophic fire spread routes the fbu
00:34:27 catastrophic fire spread routes the fbu believes the GTI must acknowledge that any firefighting is fraught with danger and that entering a compartment to fight a fire is hazardous for those tasks to undertake it for their own safety and
00:34:39 undertake it for their own safety and the safety of the public firefighters need set procedures and must follow those procedures or as has happened too often in the power risks will end in injury and death
00:34:52 risks will end in injury and death firefighters will train two procedures in order to best manage the risks and the uncertainties inherent in firefighter they work collectively to
00:35:04 firefighter they work collectively to execute set procedures in a disciplined fashion the fbu
00:35:13 considers that the fire and rescue service is a force for good in our society with a culture of decency and a
00:35:25 society with a culture of decency and a highly developed sense of duty and
00:35:30 genuine respect and care for the victims of fire and other disasters as is clear from my submissions and what follows the
00:35:42 from my submissions and what follows the fbu
00:35:43 fbu and the lfb don't agree on everything but we do agree on a lot and the fact that I'm focusing perhaps in these
00:35:56 that I'm focusing perhaps in these closing submissions on those areas in which we disagree shouldn't have paint the false picture that the FPU doesn't fully respect the earthly and the work
00:36:08 fully respect the earthly and the work it does
00:36:12 firefighters had no experience of a fire in a high-rise block that could that could not be extinguished before Graham from tower and no experience of
00:36:27 from tower and no experience of requiring - or moving to an evacuation those were new new concepts for all the firefighters who attended those who
00:36:39 firefighters who attended those who attended tried to extinguish the fire and save lives they did their duty professionally bravely and to the best of their abilities in face of an initially insidious and rapidly developing fire they didn't startle
00:36:50 developing fire they didn't startle cause they followed their procedures and applied their training as much as the extreme conditions allowed their procedures training and experience did not prepare them for either declaring
00:37:01 not prepare them for either declaring fire with its potential for rapid fire spirit or a full or or partial evacuation of a high-risk residential building let alone may I say total
00:37:14 building let alone may I say total building failure you know but may I repeat that by starting with a micro analysis of the emergency response the
00:37:27 analysis of the emergency response the GTI risks inflating the significance of anything the emergency services might have done differently in face of the unfolding disaster it can't explain how the building became a highly combustible
00:37:38 the building became a highly combustible deathtrap nor why that deceased be ourselves and the emergency services were put in the awful we say impossible given the procedures and training and experience they had the impossible
00:37:49 experience they had the impossible position of dealing with the inferno that resulted
00:37:56 with ask you please mr. chairman to approach phase one findings effect in what we call proper perspective and there are several aspects to this we
00:38:10 there are several aspects to this we fully understand the BS R's grief and their pain and their need to know facts and their understandable need to blame
00:38:23 and their understandable need to blame somebody but for the loss of their loved ones but as others have said we ask you to assess the response taking into
00:38:34 to assess the response taking into account that the firefighters didn't have to benefit of hindsight then there's the the perspective of the the
00:38:46 there's the the perspective of the the unknown dangers that the firefighters were encountering I won't read out what I've put in the closing submissions about dr. lanes opinion because she's already been referred to so extensively
00:38:58 already been referred to so extensively but I do support the the request by Stephanie Barr wise QC for findings of fact in respect of non-compliance of the
00:39:12 fact in respect of non-compliance of the rain rain screen clearing system and of the refurbishments amounting to a material alteration when in fact
00:39:24 material alteration when in fact material alterations
00:39:34 can I add to that the fire safety measures inside a graphical tower that the FB you would it's obviously a matter
00:39:46 the FB you would it's obviously a matter for you but we would say there there is no good reason not to make findings effect also in respect of they are not being a working fire lift they're not
00:39:58 being a working fire lift they're not being a web browser and they're not being a an adequate smoke extraction system
00:40:15 so moving if I may to the main thrust of of the FB use submission and that is that we do of course accept that things
00:40:30 that we do of course accept that things could have been done better but we accept that with the benefit of hindsight and knowing what should have gone on before both by way of proof our
00:40:42 gone on before both by way of proof our preparation and most importantly in terms of developing procedure for evacuation and training firefighters on
00:40:53 evacuation and training firefighters on that procedure so that the instant commander would have had a workforce that was able to implement a procedure
00:41:04 that was able to implement a procedure and would have known what to do that didn't exist so I'm now at paragraph 10 of my submissions and the the first
00:41:17 of my submissions and the the first point of importance is that the responsible person the Royal Borough of Kensington and Chelsea had never vacua ssin plan for Greenville town doubtless
00:41:29 ssin plan for Greenville town doubtless the Royal Borough would disagree and say it had a statehood strategy but a staple strategy is not an evacuation plan and I've set out there a transcript of the
00:41:43 I've set out there a transcript of the far action notice that's was photographed and and was posted by than the lifts on the ground and other floors and the reason I've done that is to to
00:41:54 and the reason I've done that is to to make it legible because in the photograph it's actually quite difficult to read the other text but if you see on on page six of my submissions the words on arrival the fire brigade will make an
00:42:06 on arrival the fire brigade will make an assessment and will assist with evacuation if required and so there there can be no doubt from the Kensington and Chelsea point of view and from TMS point of view there was in
00:42:20 from TMS point of view there was in their minds an idea that there might be a require
00:42:25 a require for an evacuation and if there was the fire brigade would make an assessment and assist with it moving on to to the the legal duties I
00:42:37 moving on to to the the legal duties I cite their articles 14 and 15 of the fire safety order and it's it's the F to be used contention that the the
00:42:49 be used contention that the the responsible person and the building owner in this case was required to ensure that relevant persons that includes residents and their visitors could evacuate the premises as quickly
00:43:01 could evacuate the premises as quickly and as safely as possible in the event of danger and further required to establish and where necessary to give effect to appropriate procedures including safety drills to be followed in the event of serious imminent danger
00:43:13 in the event of serious imminent danger to relevant persons and to nominate a sufficient number of competent persons to implement such procedures now I do I do accept that up and down the country high-rise residential buildings did not
00:43:27 high-rise residential buildings did not have evacuation drills or safety drills residents were not treated in Manchester Liverpool or London in the way that office workers are treated or employees
00:43:40 office workers are treated or employees are treated in a factory so that one of the culture changes that the FPU asks you to consider encouraging is a culture change to treat residents in high-rise
00:43:52 change to treat residents in high-rise blocks with the same respect for their health and safety as employees in the workplace
00:44:05 the robbery committed commissioned a fire risk assessment by Carl Stokes and he also identified the possibility of
00:44:19 he also identified the possibility of the need for an evacuation so his risk assessment said and I quote the fire service or TMO employees will arrange for a general evacuation of the whole building at any time if this is
00:44:31 whole building at any time if this is appropriate to do so he was clearly envisaging that it might be either the fire service bore the TMO employees saying short the evacuation plan was for
00:44:44 saying short the evacuation plan was for residents to self evacuate and call 999 if their dwelling was affected by far - stay put if not in for the lfp or the TMO to arrange for general evacuation of the whole building if appropriate there
00:44:55 the whole building if appropriate there was no further information or guidance or training about what was meant by affected by fire nor by a general evacuation of the whole building nor when or in what circumstances such a general evacuation might become
00:45:06 general evacuation might become appropriate additionally statehood was wholly dependent upon compartment ation and needed to be supported by a contingency plan for evacuation if
00:45:17 contingency plan for evacuation if compartment ation was breached there was none we invite you sir to conclude that neither the Royal Borough nor the TMO had any procedure for the general evacuation of the whole building relying
00:45:28 evacuation of the whole building relying instead on statehood and leaving into the lfpg device one if appropriate
00:45:35 properly understood when wet when read carefully the stapled evacuation strategy actually directs the residents to leave if affected by smoke heat or
00:45:46 to leave if affected by smoke heat or fire and so the label is misleading and that may have contributed to a culture of stay put rather than leave or as Mike Mansfield said yesterday to get out and we would
00:45:59 said yesterday to get out and we would certainly support the need for a culture change to understand what has become known as tape or better as if in doubt get out
00:46:09 get out we'll leave but that's a matter for experts and we're not making that as a concrete proposal it's a matter for experts to consider we note that the
00:46:22 experts to consider we note that the Royal Borough of Kensington and Chelsea has changed the state good advice for some properties which have been risk
00:46:33 some properties which have been risk assessed as not reaching a high degree of compartment ation that would be rare unless necessary to support a step of strategy and we welcome that it's clearly a move in the right direction
00:46:45 clearly a move in the right direction and we hope that other building owners will take the same line whether the advice in the fire risk assessment that the fire service or TMO employees would
00:46:57 the fire service or TMO employees would arrange for general evacuation of the whole building or that on arrival the fire brigade would make an assessment and assist with the variation of needed was brought to the attention of interval um if B would be a matter for thee for
00:47:09 um if B would be a matter for thee for phase 2 if so it certainly hadn't filtered down to operational crews much manager Delton was aware that the majority of high-rise residential blocks had a staple policy but he had no
00:47:20 had a staple policy but he had no further information about it and was unaware he was supposed to make an assessment on arrival and assist with evacuation if needed none of the firefighters who attended grim filter if I could remember either
00:47:31 grim filter if I could remember either an evacuation plan for such a building or any training or experience in how to do so on the 14th of June implementing an evacuation plan was still unchartered territory lift to the instant commander
00:47:43 territory lift to the instant commander to navigate in the worst possible circumstances so that's the Royal power moving on now to the LF B and it's clear
00:47:57 moving on now to the LF B and it's clear that neither did the London Fire Brigade have a contingency evacuation plan for ground for town the possible need for such a plan has a long track record of
00:48:10 such a plan has a long track record of being mooted so since 1998 it was mooted in the what was then the generic risk-assessment 3.2 and although very briefly but it did nevertheless mention it and in successive editions
00:48:23 mention it and in successive editions it's been fleshed out slightly more and so we now have the the 19th 2014 edition and that is quite explicit in its
00:48:34 and that is quite explicit in its aspiration they're not in the practical detail of how to achieve it so the aspiration is that contingency plans should cover an operational evacuation
00:48:47 should cover an operational evacuation plan being required in the event mistake of policy becomes untenable and the training which will cover high-rise instance must include evacuation and casualty removal tactics instant command
00:48:58 casualty removal tactics instant command assure us to understand when a partial full evacuation stretched you might become necessary the residential building where a staple strategy is normally in place and the FB use point is that neither GRA 3.2 nor any other
00:49:11 is that neither GRA 3.2 nor any other policy gave any guidance then or in subsequent editions only how to evacuate such a building involved in far nor on the circumstances which should trigger an evacuation national guidance was
00:49:24 an evacuation national guidance was incorporated into belif B's policy notes EPI and 633 and PN 790 those we've been looking at extensively over the course of these hearings but similarly without
00:49:37 of these hearings but similarly without advising on how or in what circumstances to evacuate in a high rising of open fire and once again leaving into the incident commander to develop a general evacuation strategy if appropriate for
00:49:48 evacuation strategy if appropriate for example so looking at paragraph 7.45 of PM 633 the incident commander should consider following the evacuation plan devised as part of the optimized fire
00:49:59 devised as part of the optimized fire risk assessment unless the fire situation dictates otherwise but as we've seen there was no evacuation plan that the occupied paragraph seven point four six advised
00:50:12 paragraph seven point four six advised it may be necessary to undertake a partial full evacuation in a residential building where a state book policy is normally in place but no guidance when or in what circumstances and paragraph four point seven
00:50:25 and paragraph four point seven highlighted some of the difficulties in an instant Carter would face in such a situation such as adverse effect on firefighting which is obvious with crews going up and people coming down and
00:50:36 going up and people coming down and greater assistance needed for disabled persons but the only practical suggestions were to consider additional resources using other emergency personnel to assist and establishing separate attacking evacuation of
00:50:47 separate attacking evacuation of stairwells these suggestions have little or no value to the instant command regretful there's no point in having more resources unless there's a plan
00:50:58 more resources unless there's a plan they're trained in to execute and it was unsafe for the police and paramedics to enter the building and there was only one stay away so the only advice that
00:51:10 one stay away so the only advice that was given in the policy was of no use to the incident commander the LFP does now to his credit admit that pm-63 does not
00:51:21 to his credit admit that pm-63 does not provide specific guidance on evacuation I psyched paragraph 84 of their closing submissions but he deserves that not
00:51:33 submissions but he deserves that not every breach of compartment ation leads to a full evacuation the FBO accepts that of course but the point is that if
00:51:45 that of course but the point is that if if there is a breach of compartment ation then the question arises is there a real risk that it's going to be a widespread breach of compartment ation and it's foreseeable that such a a
00:51:58 and it's foreseeable that such a a widespread breach could occur to come on to that in a minute but if if that should occur then there would be a need for evacuation and the lfp assert that
00:52:12 for evacuation and the lfp assert that policy note 434 on sector ization provides a means to pass a curation for localized breach of compartment ation that's paragraph 27
00:52:23 compartment ation that's paragraph 27 and assert it was practiced at Shepherd's court there's paragraph 28 well deputy who disagrees with with that
00:52:34 well deputy who disagrees with with that having read PN 434 recently it's wholly silent on evacuation provides no guidance or procedure for evacuation it is a policy note on Secretary's ation
00:52:47 is a policy note on Secretary's ation that's all it doesn't fill the gap we're left with no no procedure for evacuation we ask the Chairman to conclude that
00:52:58 we ask the Chairman to conclude that neither the ill sorry and Shepherds Court yes well if it was practiced at the Shepherd's caught if there was a localized or a partial evacuation of the
00:53:11 localized or a partial evacuation of the areas immediately affected by a localized breach of compartment ation then that learning wasn't captured and introduced as part of a revised
00:53:24 introduced as part of a revised operational risk database information available to instant commander so it the NFP may be right about that and but it
00:53:37 NFP may be right about that and but it was of no use to the incident commander and
00:53:40 and at groennfell town so we ask you to conclude sir that neither gra 3.2 nor PN 633
00:53:50 633 nor pn 4-3 fault if you feel obliged to deal with it gave any practical guidance to incident commanders on how to evacuate and a high-rise block involved in fire nor on the circumstances which
00:54:01 in fire nor on the circumstances which should trigger an evacuation there is as yet so far as the FPU is aware no Fire and Rescue Service in the UK that has
00:54:12 and Rescue Service in the UK that has developed a contingency evacuation the FPU have conducted survey it's not completed yet there's a few outstanding ever
00:54:23 ever which haven't responded but that's the position so far that there isn't a single Fire and Rescue Service that has developed contingency so the RFP is if
00:54:36 developed contingency so the RFP is if you like into a company and but we say this is this reflects that the difficulty of the task
00:54:46 there's no task analysis of who does what which we say is a necessary step to ensure resources arriving early enough
00:54:57 ensure resources arriving early enough to put evacuation into practice if circumstances require it we hope in phase two the inquiry will consider why neither responsible persons nor the Fire
00:55:10 neither responsible persons nor the Fire and Rescue Service nationally head develop contingency evacuation plans in the event of a breach of compartment ation rendering statehood unsustainable in the Harz going forward and we welcome
00:55:23 in the Harz going forward and we welcome the elephant's commitment to review the P and 6:33 with recreation in mind but we're disappointed that the Ministry of Housing and Communities and Local
00:55:34 Housing and Communities and Local Government MHC o G is still silent on any national research and development for national guidance for an evacuation
00:55:47 for national guidance for an evacuation plan to be rolled out to local Fire and Rescue Services and for them to apply locally in their standard operating procedures or policy notes however they
00:55:58 procedures or policy notes however they do it and and to be embedded with training we're 18 months after burn for the need for an evacuation plan is stark
00:56:09 the need for an evacuation plan is stark and occurring Michael Mann schools sentiment yesterday The Times Now
00:56:21 we do suggest this is paragraph twenties the developing such procedures would require a considerable investment of resources including empirical studies trials the bringing together of
00:56:33 trials the bringing together of expertise in a number of different fields of discipline liaison with responsible persons development of a general evacuation procedure to be practiced reviewed improved and implemented were needed and practical
00:56:44 implemented were needed and practical drills each one involving hundreds of residents their visitors wardens and others this would have been a major undertaking achievable only at the national level we say it was too daunting even for the biggest farm
00:56:56 daunting even for the biggest farm Rescue Service in the country the LF being to resolve it was a challenge for central government this is not a problem to be delegated to individual foreign
00:57:07 to be delegated to individual foreign rescue services nor even the National Fire Chiefs Council it's certainly not one to be given to an incident commander to resolve in the midst of an emergency
00:57:18 to resolve in the midst of an emergency not only was it impossible for and what's well to tell them to devise a workable evacuation plan in such circumstances but also it would be impossible to implement any plan he
00:57:29 impossible to implement any plan he might devise without a work force trained to execute it and he told the inquiry when asked and if you had decided to adopt a strategy of full-scale evacuation can you give me
00:57:41 full-scale evacuation can you give me some kind of idea of what you would have needed in terms of firefighters and equipment at that moment and his answer I can't comment on that because there's something I've not had experience of
00:57:53 something I've not had experience of it's a hypothetical question and I really only want to talk about my recollection of the night what I did and my actions we asked the Chairman to conclude that the instant commander was placed in an impossible position without
00:58:06 placed in an impossible position without an evacuation procedure in place so moving on to training it's very much the FP use approach that there must be a
00:58:20 the FP use approach that there must be a procedure first then you can have the trading on the procedure then you might be able to implement it and in looking at training that probably provides the
00:58:31 at training that probably provides the answer to the there there are clear training gaps the evidence is almost entirely consistent that there was very
00:58:43 entirely consistent that there was very little or no training on evacuation or changing the stay-put strategy on
00:58:52 widespread breach of compartment ation on cladding fires or on multiple FSGS and without boring everybody with the
00:59:08 and without boring everybody with the details
00:59:08 details I've set them out paragraphs 23 yes and I trust that you'll take those into account be if I can just explain it in
00:59:20 account be if I can just explain it in in a nutshell we've looked at what Assistant Commissioner Road told inquiry about training or the lack of it and then we've seen how that is reflected in
00:59:31 then we've seen how that is reflected in the evidence of the firefighters who attended on the night and going through the instant command chain and and then taking a selection of firefighters and it's pretty consistent and their crew
00:59:44 it's pretty consistent and their crew manager secret seems to sum it all up so in terms of the training and experience with evacuation or changing the stay-put strategy crew manager secret said this
00:59:56 strategy crew manager secret said this is error of 25e the training does not cover how to assess whether the state book policy remains a safe policy to retain in the event of a failure of compartment ation in a long and what signs to the count fault
01:00:09 long and what signs to the count fault opposing there because that lack of training was mirrored in control and so
01:00:20 control also had no such training on on how to move from a stay put strategy to any other strategy and
01:00:34 assistant operational manager Alexandra Norman said that she was never trained on how to make that assessment as to whether recorder should evacuate or stay put and Senior Operations Manager Smith
01:00:48 put and Senior Operations Manager Smith told the inquiry that she was not familiar from either training or experience with the idea that the alternative to stay put is simultaneous evacuation and once it's understood
01:01:00 evacuation and once it's understood there was no evacuation procedure and their training on it this all becomes clear of course that's why there's no training they went to escape your notice
01:01:11 training they went to escape your notice said that relatively junior officers were left in charge both at the far ground until 150 157 and in control
01:01:25 ground until 150 157 and in control assistant operations manager was not a senior operations manager she was an assistant operations manager and the same the same rank as some of her
01:01:36 same the same rank as some of her colleagues who were acting in a supervisory role in the control room and she was in control there until in command there rather than till 2:15 the FPU says that this this reflects the
01:01:49 FPU says that this this reflects the rapidity and the speed of the far development which literally overwhelmed and overtook the LF these procedures in
01:02:00 and overtook the LF these procedures in this case it's the procedure to make up to a more senior management or command structure so I
01:02:12 management or command structure so I won't go into the specific details of that training and invite you to to read those those paragraphs what I should deal with there is is what what
01:02:23 deal with there is is what what surrounds our Peter Johnson said what's manager Peter Johnson identified that pn7 90s paragraph 34 so that pn7 90 did not adequately take him to account the
01:02:35 not adequately take him to account the potential for fast bread at a high rate instant and did not anticipate multiple if this recalls there being no training package he devised one for handling these calls and he said that the trade
01:02:48 these calls and he said that the trade package I designed demonstrates how difficult it would be to deal with just seven if it's cheese and that the FSG policy was unrealistic the communication information required to be passed on to
01:02:59 information required to be passed on to control by control to the FSG command unit becomes difficult with only four if this G's he tried to remedy matters you'll remember so that he took it to the policy review committee and he took
01:03:10 the policy review committee and he took it to Badcock but PN's civil 90 was never amended to cater for multiple FS cheese and no trading package sufficient to deal with
01:03:21 trading package sufficient to deal with the difficulties in communicating if multiple if it's G's was ever designed again we we submit that this is reflective of the lack of an evacuation procedure because the the solution is
01:03:36 procedure because the the solution is probably not to amend it PN 790 the procedure say it's safe to say that if you're getting FSG calls from different parts of the same building then you
01:03:50 parts of the same building then you should be considering the full password situation but without that option people
01:04:01 situation but without that option people are rather stuck is taught to do it's notable that assistant operations
01:04:12 notable that assistant operations manager Norman gave mirror evidence of such a lack of such training in the control room for dealing with FSG calls and mr. Walsh has already outlined the
01:04:26 and mr. Walsh has already outlined the very limited experience of FSG calls which I won't repeat
01:04:37 so there could be no magic solution to the problems of trying to handle multiple FS cheese without an evacuation
01:04:49 multiple FS cheese without an evacuation plan going forward betrayed such training in future would have to be founded on procedures and cover with we've set out a few ideas
01:05:01 cover with we've set out a few ideas there but we don't pretend that that is a fool because as I said earlier it's a metaphor
01:05:08 metaphor experts probably at a national level to develop a procedure and to work out the training for it so conclusions on the lack of Arthur an evacuation plan or a
01:05:20 lack of Arthur an evacuation plan or a contingency evacuation plan before Greenville no Fire and Rescue Service across the country had developed such a one the total building failure of Granville lies at the heart of all the major problems faced by the emergency
01:05:31 major problems faced by the emergency services on the night however even recognizing that a lack of any practical contingency evacuation plan and the training and confidence to implement it
01:05:42 training and confidence to implement it limited the good work which the emergency services could do eventually when the fire had developed significantly dr. Lane reports that by 225 so just before the staple device was
01:05:56 225 so just before the staple device was to change three of the four elevations had had ignited and so as I say when the fire had developed significantly very senior officers changed the state would
01:06:07 senior officers changed the state would advise until then the training and experience of the firefighters in control room staff present did not allow them to devise any alternative strategy says it's notable we says within about
01:06:20 says it's notable we says within about 20 minutes of senior operational manager Smith's arrival in control she began to change the statehood advice from about 2:35 she got to control about 2:15 and
01:06:31 2:35 she got to control about 2:15 and she she started to change it from 2:35 until then the control room staff could only apply their experience and to make sure the FSG data was passed the
01:06:42 to make sure the FSG data was passed the far ground in the well-founded belief that the firefighters would rescue the efficacy callers who they believed were safest remaining in their flats and awaiting rescue some undoubtedly gave
01:06:54 awaiting rescue some undoubtedly gave the wrong advice I know we've we've listened to the some of the calls and we've read the transcripts and it's undeniable that that doesn't look good
01:07:06 undeniable that that doesn't look good on in black and white but the FPU asks you served to find that the these mistakes were made they were well-intentioned they were
01:07:17 they were well-intentioned they were made with the intention of comforting and reassuring and helping and in the belief that the firefighters would get to rescue people who needed to be
01:07:29 to rescue people who needed to be rescued and that the firefighters would extinguish the fire that was the experience of people in control that's what they expected to happen
01:07:43 and likewise the same point applies at the on the on the fire ground didn't when when Assistant Commissioner arrived on the interesting ground he
01:07:54 on the interesting ground he independently and more honest immediately reached the same decision to change statehood advice at around 247 and until that point the firefighters could only apply their experience and
01:08:05 could only apply their experience and training to someone more resources to fight the flat fire then to attempt to fight further flat phones to attempt to fight or slow the fire externally to preserve and pass on carefully the FSG
01:08:16 preserve and pass on carefully the FSG information they were given to search and try to rescue history cause and to assist evacuees and rescue or recover casualties without a contingency evacuation procedure and the training to
01:08:28 evacuation procedure and the training to embed it the firefighters in control room staff were placed in an impossible position as mr. Dowd and told the inquiry when asked about the type by mr. Munoz about the time at about 124 when
01:08:41 Munoz about the time at about 124 when the fire was rapidly developing up the east elevation and he just made comes tin he said for me at that moment in time to facilitate and change a state book policy to a full evacuation was
01:08:52 book policy to a full evacuation was impossible I didn't have the resources at that time we're looking at 20 floors above the fire floor with just six fire engines and attendants one central staircase is something I've never
01:09:04 staircase is something I've never experienced as an instant commander before as I said I was very very very and I said enough theories much out of my comfort zone I just don't know how that could have been done with the
01:09:15 that could have been done with the resources we had in attendance at that moment in time they're not thoughts I had at the time that's a reflective thought that you know I've had a lot of time to think and process the event which I didn't have on that night I
01:09:26 which I didn't have on that night I didn't have the time for those reflective moments I was reacting in a way that I thought was best with all my previous experience in something that I've never witnessed before and you know yes and when asked about the time a
01:09:40 yes and when asked about the time a little bit later at 1:29 when he made pumps 20 and fire rescue units to horse rented out and said I would say at that point I was still working to the state
01:09:51 point I was still working to the state policy because of my previous experience and I've not been in a position before where I've ever had to make that decision or change that advice I served we say that that is the
01:10:03 I served we say that that is the consequence of not having an evacuation and evacuation plan so if I can just turn to a few issues first of all
01:10:14 turn to a few issues first of all foreseeability and the question arises foreseeability by human of what foreseeability what was
01:10:31 by human of what foreseeability what was foreseeable by the London Fire Brigade that was probably different from what was foreseeable by the firefighters on the far ground so there's a clear difference between the systemic institutional information that was available to them and the information
01:10:45 available to them and the information that was available to the incident commander and the other firefighters in the ground now what was foreseeable the EPI would agree that total building
01:10:57 EPI would agree that total building failure of the kind that happened to Graham fell was probably unforce evil it was so beyond people's comprehension that that so many fire safety measures
01:11:11 that that so many fire safety measures could fail and that the fire could spread so rapidly was there probably unfishable but we say that's that's not
01:11:22 unfishable but we say that's that's not what matters what matters in this context is was it foreseeable that there could be a widespread breach of compartment ation such that the stay put strategy became our sustainable so that
01:11:37 strategy became our sustainable so that an evacuation became necessary and and we say that that was foreseeable
01:11:49 and we say that that was foreseeable clearly foreseeable to the NFB albeit not foreseeable to those who were not privy to the tool building facades
01:12:01 privy to the tool building facades presentation and the information that was available for example I think we were told that there was a local newspaper picked up on the ship it's
01:12:12 newspaper picked up on the ship it's called fire but but otherwise there was no widespread dissemination of the learning of the ship it's caught fire so I dealing just with the lfb as an
01:12:24 I dealing just with the lfb as an institution there was clearly knowledge that fire can break out it will break out kitchen fast a relatively common that fire can spread over the exterior
01:12:38 that fire can spread over the exterior of buildings so much is written about it it's quite obviously foreseeable and it's happened and we have the examples of of cladding fires spreading rapidly
01:12:50 of of cladding fires spreading rapidly and breach a compartment ation and we know that breach of compartment ation can be localized as well fire fighters spoke of but it can also be unpredictable and fire being
01:13:03 unpredictable and fire being unpredictable is one of the things that's known about fire and so putting all that together it is we say it was foreseeable that the need for an
01:13:16 foreseeable that the need for an evacuation plan could arise and that it should have been in place
01:13:24 so turning if I may to pick out one or two issues I'm not going to go through the whole of the closing submissions they're there for you to read but I feel
01:13:38 they're there for you to read but I feel like it's important to deal with some allegations in particular the lone friend mr. Brown has written lengthy submissions in respect of the evidence
01:13:50 submissions in respect of the evidence of mr. norman harrison who as you recall went to see you ate and stood on the steps and and declared his belief that
01:14:02 steps and and declared his belief that the state of policy should change that you may find is is of significance you may find it's not of any significance it very much depends on the timing of of
01:14:15 very much depends on the timing of of that mr. Brown's analysis is very careful and we don't dispute his analysis of the timing and if as he
01:14:27 analysis of the timing and if as he concludes that episode on the steps of cu8 took place after 3 o'clock in the morning then you may conclude it's it's not something that you need to make a
01:14:39 not something that you need to make a finding effect about because by that stage the stupid advice that changed in both control and on the far ground
01:14:48 otherwise it's it's a conflict of evidence and we have we leave that to you mr. Herrera has been singled out for
01:14:59 you mr. Herrera has been singled out for criticism we ask that there be no findings effect in respect to mr. Herrera for the reason that the evidence
01:15:14 Herrera for the reason that the evidence at the moment is incomplete in that respect but also for this reason that although it would appear that there is a conflict of evidence as to what was said
01:15:26 conflict of evidence as to what was said and let me be quite clear the FB you does not suggest that Omar our journey is is lying that is not any part of the
01:15:37 is is lying that is not any part of the FBS position we accept entirely that he would not have knowingly said anything about his brother that would have left to him being led to him being left
01:15:49 to him being led to him being left behind but what we do say is that these were dynamic changing conditions that visibility was fluctuating and at times
01:16:00 visibility was fluctuating and at times nil and certainly nil in the lobby and that there was ample scope for misunderstanding and mistakes to be made
01:16:11 misunderstanding and mistakes to be made and that mr. Herrera was speaking through a mask and that is another good reason for a misunderstanding in a mistake so we ask that the there be no
01:16:24 mistake so we ask that the there be no findings in that regard at this stage but that if you do disagree and you feel it is necessary to make a finding then to take into account the really quite
01:16:37 to take into account the really quite dramatic conditions you've heard the residents in that flat speak of of their their growing fear the increasing amount of smoke in the flat
01:16:49 increasing amount of smoke in the flat leading to the possibility of jumping out for windows and so that was a highly charged atmosphere into which a firefighter walk there's also the issue
01:17:01 firefighter walk there's also the issue of the the door and the position of the door in the bedroom where the bed was where several of the of the four who were left behind were situated and it
01:17:12 were left behind were situated and it may be that the way that door opened into the room obscured mr. Harris view of who was in that room so there's an awful lot to take into account in
01:17:24 awful lot to take into account in reaching any conclusions about that episode and the the whole approach of the FPU in the in this situation is to
01:17:37 the FPU in the in this situation is to say look the residents were put in a position they should never have been in the firefighters were put in a position they should never have been in and had
01:17:48 they should never have been in and had there been an evacuation procedure that could have been executed then this situation wouldn't have arisen and of
01:18:00 situation wouldn't have arisen and of course we go back further than that and say that if the building hadn't been handed over with a staple strategy it wouldn't have arisen either so going forward I see you looking at the clock
01:18:12 forward I see you looking at the clock and I've only got a few oh you look at me I do apologize that that's my eyesight again so I've only got a few other things to deal with I want to touch on the predetermined attendance
01:18:25 touch on the predetermined attendance the PDA and you know what it was obviously it was four pumps and they arrived as sentence and paragraph 48
01:18:44 and notably it did not include an aerial appliance any fire escape hoods any EDB
01:18:55 appliance any fire escape hoods any EDB a an officer in or higher than the rank of station manager nor a handheld over air wave radio and additionally as as
01:19:06 air wave radio and additionally as as can be seen in our little table they were only ten firefighters available initially to implement P and 633 and mountain attack on the fire in flat 16 and the front doors that was forced open
01:19:20 and the front doors that was forced open at 107 so the firefighters arrived founder a well developed fire and attacted in the way they were trained to do and they extinguished it and you
01:19:33 do and they extinguished it and you heard watch manager O'Keefe say that he was quite impressed it was a good job distinguishing that fire the the five
01:19:45 distinguishing that fire the the five who ascended the tower to totally protect that fire set of a bridge headed and fight the fire were unaware of of the prospect of fast bid on the exterior
01:19:59 the prospect of fast bid on the exterior they went into the building unaware of what was going to happen on the outside
01:20:04 the NFB have since increased the PDA for as an interim measure as the FB you requested I should say on the night all
01:20:19 requested I should say on the night all all 20 firefighters were very busy implementing p.m. 633 and because they were so busy in the early stages as
01:20:30 were so busy in the early stages as laying out hoses and all the other got to do there was no one to staff the radio on the icy pump nobody to look out for reach of compartment ation on each face of the building internally above
01:20:44 face of the building internally above and below the fire flat and no one to conduct a 360-degree Rickey or to check the internal fire safety measures so going forwards in future the PDA must we
01:20:55 going forwards in future the PDA must we say be resourced sufficiently to carry out the tasks required to implement both P and 63 and an evacuation procedure if appropriate on arrival of the scene more resources that are needed can arrive
01:21:07 resources that are needed can arrive early if they're not needed they can go the Fire Brigades Union believes it's legitimate to ask what difference an earlier arrival of a turntable ladder could have made assuming similar traffic
01:21:18 could have made assuming similar traffic conditions had the turntable had have been mobilized at at the time of the PDA at over 55 it could have been on the scene at 13 and the same time sorry Oh
01:21:31 scene at 13 and the same time sorry Oh 113 and at the same time firefighters
01:21:37 that was the same time that firefighters actually in the events that transpired asked for a higher platform and that it
01:21:49 asked for a higher platform and that it was amended to an aerial at 114 but it's likely that the turntable ladder would have been more effective than firefighters at ground level directing a hose upwards and the deployment of the
01:22:01 hose upwards and the deployment of the ground monitor the FBI believes this question is valid in light of the NFP is past practice and its subsequent decision after Grenville tower in the
01:22:12 decision after Grenville tower in the past the NFB routinely sent a real appliances to high-rise instance until the first safety plan in 2005 and since then these vehicles have been on request
01:22:23 then these vehicles have been on request a consequence it counts the LF B's document actions since the Grenville tower fire indicates that since the 22nd of June 17 has changed its interim PDF
01:22:36 of June 17 has changed its interim PDF for high-rise buildings to at least five fire engine one area clients and this indicates that the previous PDA was insufficient even
01:22:47 the previous PDA was insufficient even if you sir concluded an aerial would not have enabled firefighters to extinguish the external cladding fire which is entirely possible because of course the rainscreen cladding would have made
01:22:58 rainscreen cladding would have made difficult for aerial its failure to do so is failure to be effective on an external fire may have helped the instant commanders perception and
01:23:09 instant commanders perception and understanding of the futility of firefighting as it was he was awaiting the arrival of an aerial which he was hoping was going to be able to make a difference to the fire it didn't arrive
01:23:21 difference to the fire it didn't arrive until 1:30 - oh I think it was 132 and and thereafter it had no effect but the incident commander had to wait for that
01:23:32 incident commander had to wait for that to arrive before he could see will have no effect
01:23:38 so moving on to the next issues the operational risk database and 70 DS on
01:23:49 operational risk database and 70 DS on reach much better doubt and also aware this was cool to a fire with dry riser in a high-rise and from the mobile data terminal he printed on on his fire
01:24:01 terminal he printed on on his fire engine he printed off the technical plan for Greenville town which was dated as we we'll know 30th of October a nine well out of date from the LF B's
01:24:13 well out of date from the LF B's operational risk database and this contained no warning there was an external rainscreen cladding system all there was a combustible building envelope and there was no information about an evacuation plan and of course
01:24:28 about an evacuation plan and of course it had no plans they wrongly described 20 floors when they were 2014 stood they were actually 24 it advised various points there including that there was a
01:24:41 points there including that there was a staple policy but the and there was no information and premises information box at Grove hotel no concierge or was a representative of the responsible person who was there to
01:24:52 the responsible person who was there to to answer questions until much later when the lay low arrived and the and mr. Layton didn't arrive until around 2:30
01:25:04 so that the attending cruise with us given out-of-date and inaccurate information and the FPU considers a sufficient time and resources should be allowed to enable fire crews to conduct
01:25:16 allowed to enable fire crews to conduct 72 d familiarization visits in accordance with PN 633 considering all the items listed in Appendix 1 in a holistic fashion and to write them up properly after it serves to maintain the
01:25:28 properly after it serves to maintain the currency and usefulness of the operational risk database it's important that you know so that these 70d inspections are done by crews who are on
01:25:40 inspections are done by crews who are on run they're available to be called to answer the call to a fire and that's what does happen they do get interrupted in the middle of Section 70 days they are disturbed in that task and so the
01:25:53 are disturbed in that task and so the FPU contends that this is serious business
01:25:57 business it's important of stuff and they there should be a proper allocation of time to enable the job to be done properly this is partly a resources issue in the
01:26:10 is partly a resources issue in the vicinity of Grenville Tower there are several fire stations closed Westminster in Knightsbridge and and Belsize in 2014 and there were several other stations
01:26:25 and there were several other stations lost a pump so Kensington lost a pump in 2005 went down from a two pump station to a one pump station and Chelsea lost pumping in 2013 likewise from a - come
01:26:37 pumping in 2013 likewise from a - come to one pump and so it's obvious that there are now fewer firefighters spread over a larger station ground - to cover the fire safety work that is allocated
01:26:51 the fire safety work that is allocated to operational crews so fewer firefighters to do more work and we say it's difficult enough to do a section 7 2d properly or a home fire safety visit
01:27:04 2d properly or a home fire safety visit and really there should be proper allocation of resources so they can be done properly
01:27:16 moving on to the issue of the covering JIT and professor Bisbee had thought about this issue and thought that the the covering jet probably wasn't applied until sometime soon before in seen on
01:27:29 until sometime soon before in seen on video at 1:15 the FPU argues that there's no good reason not to accept the evidence the firefighters who said that
01:27:41 evidence the firefighters who said that it was applied earlier professor Bisbee didn't didn't actually mention the evidence of the firefighters and it appears to have arrived to his conclusion by reference to looking at
01:27:53 conclusion by reference to looking at the video evidence
01:27:56 I just want therefore to remind you sir of of the evidence on that it was watch
01:28:07 of of the evidence on that it was watch manager doughten who explained that the puddle that was seen on the photograph could have come from covering jet being either deployed or being tested so it's
01:28:19 either deployed or being tested so it's very fair about that and we submit on the balance of probabilities the firefighter evidence should be accepted firefighter Abel recalled assisting his colleagues lay and deploy the covering
01:28:30 colleagues lay and deploy the covering jet above the kitchen window a flat 16 well we when we see the video Abel isn't there it's Murphy and Cornelius so if
01:28:41 there it's Murphy and Cornelius so if Abel did assist in deploying the covering jet above the kitchen window flat 16 it was before Murphy in Queenie's firefighter archer said in his police statement the dryer riser was
01:28:52 police statement the dryer riser was already being set in i got a 45 millimeter jet off the north Kensington's ladder rolls out and got it to work i was spraying it just above the window where the flame was coming out was seemed to be helping with the fire
01:29:03 was seemed to be helping with the fire he was soon thereafter told to rigging ba and deployed in the tower he tallied out at 120 121 and this fits with him having deployed the
01:29:16 fits with him having deployed the covering jet about 111 as estimated by the
01:29:19 the be in their operational response report
01:29:25 and that's also consistent with watch manager doubt ins instruction to apply the covering jet apartment below the window after his discussion with crew
01:29:37 window after his discussion with crew manager secret and you'll remember the good reason why the covering jet wouldn't be applied in through the window the effect of a covering jet on
01:29:49 window the effect of a covering jet on the exterior fire is a different matter altogether water from below may have been able to enter the cavity professor Bisby did explain that interesting feature of the rainscreen cladding system where water going up from
01:30:01 system where water going up from underneath might get it Gary where's water coming from about wouldn't but we submit that it's although it's possible that water from below may have slowed
01:30:12 that water from below may have slowed the fire spread it wouldn't have made a substantial difference and we submit that at most it can only have had a limited and temporary effect on the exterior fire and that's consistent with firefighter Browns evidence but when he
01:30:24 firefighter Browns evidence but when he applied water directly onto the exterior far from the window flat 16 it had no effect and he was obviously very close to the fire had no effect and with the
01:30:37 to the fire had no effect and with the evidence of firefighters Murphy in Cornelius of their application of a covering jet on the exterior appear to have no effect and we know what happened with the aerial appliance substantial cone I tend to insidious
01:30:50 substantial cone I tend to insidious fast for it obviously you're going to be guided by the experts on how the how and when the fire spread occurred and I
01:31:03 when the fire spread occurred and I don't seek to make any submissions in that regard what I do have to say and is that the spread of fire was insidious in the sense that it's
01:31:22 was insidious in the sense that it's understandable how somebody's standing outside the building could look at it and not realize just how fast that fire was written so taking it in stages
01:31:35 was written so taking it in stages this is paragraph 65 so spread out of the kitchen into the cladding from as early as 105 the fire progressed outside the kitchen of flat 16 into the external
01:31:47 the kitchen of flat 16 into the external facade however it did so insidiously in a manner that was unexpected and with no visible flaming outside it was creeping into the facade as torero said and as
01:31:59 into the facade as torero said and as dr. Lane explained by the time there was a visible flame front there had already potentially been ten minutes worth of localized heating of materials on the outside of the building and to give the
01:32:11 outside of the building and to give the reference for a so-so it's out and once it becomes visible that it's out and into the cladding then the next stage going up the east face initially the the
01:32:23 going up the east face initially the the insidious spread of fire then continues up the east face although by this point there was visible flaming on the exterior as dr. Lane points out what rendered out and had no reason to believe that the fire was going to
01:32:34 believe that the fire was going to continue to race up to the top of the tower and across all phases even when the fire is as high as the 11th floor and still a localized spar that could be potentially mitigated we now know that
01:32:46 potentially mitigated we now know that the catastrophic fire was inevitable as soon as the external facade became involved given the materials of construction however was funded Eldon was not in a position to realize this
01:32:57 was not in a position to realize this until after the fire had developed much further and we say it was reasonable for him to go on thinking he could he could extinguish his heart he could
01:33:09 and that was clearly his plan now taking the next stage to the top of the East face
01:33:18 face although slower than in some other external facade fires the fire quickly spread up to the top of the East face it traveled at roughly four meters per minute says professor arrow and from
01:33:29 minute says professor arrow and from flaws 19 to 23 within just 15 seconds bismi professor disney at his table 13 so the FPU invites you so to consider
01:33:43 so the FPU invites you so to consider how much standing at the foot of the tower how much can you actually see reliably of that fast minute you can see far above but can you reliably see which floors it's going going going up to you
01:33:56 floors it's going going going up to you and then when it does reach the top going across the crown to to watch
01:34:07 going across the crown to to watch rendered outand I ask you to to consider was there anything to indicate that this fire was going to envelop the entire tower previous external facade fires
01:34:20 tower previous external facade fires have self extinguished once they reached the top of the building so I referred to Professor Sir area supplementary report at page 59 and and his evidence on day
01:34:33 at page 59 and and his evidence on day 77 lateral fire spread is usually limited due to the relative paucity of fuel and this is again shown in previous external fires and I gave the reference
01:34:44 external fires and I gave the reference but Grenville tower had a bespoke architectural crown the Crown's construction designer materials provided a pathway for the fire laterally to spread around the tower and all the
01:34:55 spread around the tower and all the experts agreed on their this lateral mechanism of fast rate was a college professor there's been a unique situation which is the consequence the architectural features of Griffin
01:35:06 architectural features of Griffin so we submit that neither Watchmen to Delta nor any of his colleagues could have anticipated the crown would burn like a fuse which i think is the
01:35:17 like a fuse which i think is the expression was used we contend the time when it was clear that the cladding fire could not be mitigated by firefighting was after it had failed to stop at the roof I
01:35:28 had failed to stop at the roof I sometime after sometime between about 130 and 140 - I appreciate that others have said it was much earlier and it's a
01:35:39 have said it was much earlier and it's a matter for you sir
01:35:45 and now what was the consequence of this insidious fire spread much bands of doubt and implemented a plan to fight the fire externally as he had been trained but the faster it was was
01:35:58 trained but the faster it was was dynamic and by the time he was able to implement a plan it was too late the fire had moved on so for example this is 66 a he was asked he asked recovering
01:36:10 66 a he was asked he asked recovering jet on the east face for about 106 as a precaution in case the fire broke out of Flex 16 and that you might think is is
01:36:21 Flex 16 and that you might think is is very responsible and good firefighting he sees the fires getting near to the window in the kitchen and he asks recovering - by the time it could be used 111 or 115 depending on what you
01:36:35 used 111 or 115 depending on what you decide the fire had already taken hold in the rainscreen cladding system and the covering do preserve little or no use so that's an example of watch mounted Elden always being a few steps
01:36:48 mounted Elden always being a few steps behind a rapidly developing fire likewise said where it says G and H in paragraph six I'm afraid that's bad numbering should be in B and C likewise
01:36:59 numbering should be in B and C likewise he was unable to attempt to fight the external far from until the first fire risking unit arrived at 1:35 by which time it was too late the external fire had already
01:37:10 late the external fire had already reached the roof at 127 so he he clearly conceived a plan might have been a good one might not have been but it was in extraordinary conditions that he was observing and he conceived a plan to put
01:37:23 observing and he conceived a plan to put water down the exterior of the building from the roof but by the time the resources arrived to enable him to implement that plan circumstances had changed and the roof was already
01:37:35 changed and the roof was already consumed of fire similarly what should be see it looks like aged similarly an aerial to have arrived until 132 and despite preparing the ground water
01:37:46 despite preparing the ground water wasn't applied to the east facing to 147 by this time the external fire had already spread up the east elevation involved the crown since 140 to have been spreading down the North elevation and internally about 26 plants were
01:38:00 and internally about 26 plants were affected by fire so he was always one step behind finally in terms of picking
01:38:11 step behind finally in terms of picking out incidents on the night want to talk about the early incident command decisions and a paragraph 50 out 58 we set out the requests for assistance and
01:38:25 set out the requests for assistance and it's clear that what rented out and made sometimes on his own initiative sometimes prompted by others but he made requests for additional resources so he
01:38:40 requests for additional resources so he makes pump 6 at 112 and asks for a higher platform and then he gets changes that to to an aerial sorry at 113 and
01:38:54 that to to an aerial sorry at 113 and [Music]
01:38:55 [Music] that's that is he knows it's calling for more senior officers to attend and more resources and then with
01:39:07 resources and then with with the developer deteriorating situation he then makes pumps uppers as is set out there and those we we contend our reasonable responses to the
01:39:20 our reasonable responses to the developing far in front of him but clearly there's a limit to what he can do because these resources didn't take awhile to arrive and so he doesn't get
01:39:33 awhile to arrive and so he doesn't get any additional resources until 125 and 126 when the first where whether the two extra pumps from the made pump six arrived and that's the first help he gets is to other pumps arrived when they
01:39:46 gets is to other pumps arrived when they arrived they're immediately deployed inside the turret tower to help fight fire in the fires that have broken out
01:39:59 we contend that that was a a reasonable in fact an irresistible decision it couldn't reasonably have have not deployed more crews inside particularly
01:40:10 deployed more crews inside particularly is at that stage what's render O'Keefe was telling him by radio that he'd run out of be a cruise and that he needed more and asked him to make pumps eight
01:40:25 at 1:33 what's meant to Dowden and station manager loft decided not to hand over command but to put mr. loft in
01:40:38 over command but to put mr. loft in charge of FSGS that was a mutual decision arrived at home for discussion two important things arise from that firstly station manager loft a more senior officer approved our
01:40:50 loft a more senior officer approved our watch limited evidence firefighting plan so he also accept his the logic that mr. Devlin had that he should continue to
01:41:03 Devlin had that he should continue to try and fight the fire secondly it shows the seriousness and importance that firefighters attached to FSG information
01:41:14 firefighters attached to FSG information at that stage there was only only two FSG calls had been communicated by the radio operator Sharon Darby to the
01:41:25 radio operator Sharon Darby to the instant ground and those are set out at paragraph 64 and those two those two calls it's clear that both loft and Downton were aware of them in the course
01:41:37 Downton were aware of them in the course of their discussion because they refer to a couple of fhg calls for this decision to put mr. Laughlin charge of FSG calls demonstrates the importance
01:41:49 FSG calls demonstrates the importance was FSG information had to fire they've realized this is lives at stake people are trapped they need to be rescued this is really important stuff and they give it to they decide that mr. loft will
01:42:01 it to they decide that mr. loft will take over responsibility for the thereafter only to where they have their discussion but thereafter there's a rapid increase in the number of efficacy pools and we know that and they were
01:42:14 pools and we know that and they were overwhelmed in control and overwhelmed in and on the fire ground so if I can conclude by saying by looking at the
01:42:29 conclude by saying by looking at the list of issues for phase one the first issue is the existing fire safety and prevention measures of grim volterra and you've heard enough about that and you know what the f do you want and where
01:42:42 know what the f do you want and where and how the fire started the FPU and has sit this out at paragraph 43 to 45 and we accept what mr. Rajiv Menon QC said on behalf of mr. ki beti in that regard
01:42:54 on behalf of mr. ki beti in that regard and we agree with him that it's very hard to identify anything that mr. cove ad could have done better and we support
01:43:05 ad could have done better and we support his request for the findings of fact that he he seems and which he sent out in his in his closing submissions and we
01:43:16 in his in his closing submissions and we don't agree with everything that he said we don't agree that 126 is the time when the staple strategy should have been abandoned and a move to evacuation made
01:43:28 abandoned and a move to evacuation made but I think you you've you've heard me enough on that we say it's later than that and we don't quite agree with him
01:43:40 that and we don't quite agree with him on on foreseeability but I don't think the difference between us is is worth mentioning the the essence is that the need for an evacuation plan was for you
01:43:54 need for an evacuation plan was for you how the fire and smoke spread from its original seat to other parts of the building we leave that to the experts the chain of events before the decision
01:44:08 the chain of events before the decision was made there was no further savable life in the building again I think that decision was made at 7:55 and the
01:44:23 decision was made at 7:55 and the evidence hasn't really gone up and it's quite clear that there was very little savable life but that they did carry on trying to save life right until the end
01:44:35 trying to save life right until the end and the evacuation of residents and I've given you my solutions so unless I can go further thank you very much see well at that
01:44:51 thank you very much see well at that point I think we'll have a break before I invite terms mr. Brown to make a statement on behalf of the fire Officers Association so I'm gonna rise now we're
01:45:03 Association so I'm gonna rise now we're resume at quarter to 12:00 please
01:45:14 you
01:57:44 now mr. Brown you're going to make a statement for the fire officer sir at the outset the fire officers association in Richard Welsh would once again wish
01:57:57 in Richard Welsh would once again wish to express their sincere sympathy to the bereaved survivors and residents for their loss if we may respectfully say so what has been a notable feature of the
01:58:08 what has been a notable feature of the hearings in this phase is the considerable dignity shown by the Bursar's who have attended on a daily basis often in the face of harrowing evidence being heard so in our closing
01:58:22 evidence being heard so in our closing submissions we cover a wide range of areas including the position of Richard Welsh's incident commander as fire sector commander and the conflict of the evidence between mr. Welsh a watch
01:58:34 evidence between mr. Welsh a watch manager Harrison with your permission I don't propose to repeat that what I would wish to do so is to focus on what we regard is the particularly salient features that the
01:58:46 particularly salient features that the insolent commanders and firefighters on the ground had to deal with on the night and although our closing submissions address that under a number of separate subheadings for example the condition of
01:58:58 subheadings for example the condition of Grenville tower immediately before the fire the inadequacy of the active and passive firefighting measures in the tower the spread of fire and smoke over
01:59:09 tower the spread of fire and smoke over time and the stay-put strategy the reality is all of these points have to be considered together and that is because there is a single common denominator that unites them all and
01:59:20 denominator that unites them all and that common denominator is the wholesale failure of Grenville tower to meet the purposes required on its own and in that regard we are in full agreement with the
01:59:33 regard we are in full agreement with the BS ours
01:59:33 BS ours the lfb and the FB you and I do not propose to repeat at the detail of any of the submissions made by those core participants can I say please so
01:59:47 participants can I say please so initially
01:59:48 initially that we would respectfully invite you to have regard to a number of matters when considering the evidence of all lfb personnel both those making command decisions and those executing those
01:59:59 decisions and those executing those decisions furnace requires that their actions should not be assessed with a very considerable benefit that hindsight allows firefighters who enter the tower
02:00:11 allows firefighters who enter the tower did so with the sole aim of saving the lives of those who are trapped in it many did so at risk to their own lives and then do so they acted with bravery many attempted search and rescue on
02:00:24 many attempted search and rescue on floors far above the fire floor without firefighting media those nel FB command decisions inside and outside the tower were we would ask you to find motivated
02:00:37 were we would ask you to find motivated solely by taking decisions that would in their honestly help you facilitate the rescue of those trapped in the tower that they failed to save the lives of all those who are trapped was and
02:00:48 all those who are trapped was and remains a great source of sadness and regret to them in considering the actions of all of the lfb personnel it must at all times be borne in mind that
02:01:00 must at all times be borne in mind that this tragedy was wholly unprecedented in its scale and complexity and the enormous challenges it posed and we know that you will bear in mind that none of the firefighters had any knowledge that
02:01:12 the firefighters had any knowledge that grenfell tower was clad in such highly combustible rainscreen cladding we agree with mr. men on Queens council about the caution that should be exercised at this
02:01:23 caution that should be exercised at this stage in making value judgments about the actions of any lfb personnel in the absence of detailed evidence of the kind to which he referred and that is
02:01:34 to which he referred and that is particularly so when one has regard to the small window of opportunity about which dr. Lane has opined and we will return to that in due course can I then
02:01:46 return to that in due course can I then please just select some features of dr. lanes evidence is relevant to the tower that are particularly potent in highlights the challenges that were
02:01:57 in highlights the challenges that were faced by lfp personnel in fighting the fire and in search-and-rescue doctor lanes overall conclusion was that there were multiple catastrophic fire routes
02:02:09 were multiple catastrophic fire routes created by the construction form and construction of detailing that was used once the fire was within the planning there was nothing to impede the spread
02:02:20 there was nothing to impede the spread of fire and smoke around the building which and I quote created the conditions for a catastrophic fire event to occur the single staring the lobbies and the fire safety provisions were not ever
02:02:32 fire safety provisions were not ever designed to create a safe escape routes or a safe working environment in the whole building fire the design approach for high-rise residential buildings is based upon inhibiting that from
02:02:43 based upon inhibiting that from occurring as dr. Lane herself pointed out the design of firefighting stairs in high-rise residential buildings requires the provision of a smoke control system
02:02:54 the provision of a smoke control system functioning fire resistant closures around the lobby and the stairs including functioning fire doors to flats and the stairs any rioters protected where they pass through the
02:03:05 protected where they pass through the lobby and the system is intended to prevent smoke entering the stairs when two stair fire doors are open on the fire floor and the floor below the net effective essen of what we set out in
02:03:17 effective essen of what we set out in paragraph seven of our submissions is that those lfb personnel who are taking command decisions on the night had no prior opportunity to consider their firefighting and rescue tactics as well
02:03:30 firefighting and rescue tactics as well as any of action evacuation guidance to the residents have in regard to how the fire was likely to behave and spread once it was on the exterior of the building turning them to some salient
02:03:42 building turning them to some salient features of the active and passive firefighting measures and their inadequacy of critical importance to the ability to effectively firefight and carry out search and rescue or the
02:03:53 carry out search and rescue or the following the low bridgehead location and large fire sector reduced the time available to conduct rescue operations at higher levels whilst wearing breathing apparatus
02:04:05 breathing apparatus above the bridgehead the heat and smoke within the lobbies either prevented or reduced access to the fire main and prevented or reduced ability to find and locate occupants the impossible scale
02:04:19 locate occupants the impossible scale and nature of the task facing both residents and firefighters that night is in captured capsulated by dr. lane when she said this there were substantial signals of danger to residents and to
02:04:31 signals of danger to residents and to firefighters this included large quantities of thick black smoke which impacted sight and breathing immediately outside flat entrance doors intense heat outside flat entrance doors heat and
02:04:43 outside flat entrance doors heat and smoke in the stairs themselves rapidly advancing fire and smoke entering the flat flats me X total wall and ultimately horrific and rapidly increasing the numbers of fires for the
02:04:54 increasing the numbers of fires for the residents to attempt to escape away from within their own flats it is her opinion that the conditions created difficult and at times life-threatening conditions for the LF beam those conditions greatly
02:05:06 for the LF beam those conditions greatly restricted their ability to implement the standard processes and procedures regarding fire fighting once the fire spread beyond a flat 16 can I mention stay put briefly please it is beyond
02:05:19 stay put briefly please it is beyond question that high-rise residential buildings were handed over for occupation on the basis of a stay put defend in play strategy and without active or passive protection measures to
02:05:31 active or passive protection measures to support a change in that strategy as a result this is how the fire brigade encounter buildings in the events of fire and so the understandable assertion
02:05:42 fire and so the understandable assertion that stay put should have been changed sooner than it was must be considered against that fundamental principle of building design also sory considering
02:05:54 building design also sory considering the ability to deliver any plan which might have been formulated to evacuate residents within the window of opportunity identified by dr. lane the following are of in our respectful
02:06:05 following are of in our respectful submission critical importance it by o157 there were already many reports of
02:06:16 there were already many reports of person was trapped on floors 10 12 14 16 through - 18 20 22 and 23 with smoke or flames reports was coming into their flats as early as over 120 there was
02:06:29 flats as early as over 120 there was heavy smoke logging on the fifth floor bio 121 the fire had reached the 11th at Oh 123 there was heavy smoke logging on the 8th floor lift lobby with a lift
02:06:40 the 8th floor lift lobby with a lift lobbies getting smoker some smokier as firefighter who burn ascended Oh 128 the 15th floor lift car was filled with black smoke and at the same time there
02:06:53 black smoke and at the same time there was thick black smoke down to the ground on the fifth floor we highlight other features that set pad on paragraph 37 through 240 of our written submissions
02:07:04 through 240 of our written submissions and I won't repeat those can I then turn please to two other matters and they are the viability of self evacuation which
02:07:16 the viability of self evacuation which we deal with it's a paragraph 98 on page 32 and finally whether the evacuation of all residents was a realistic practical
02:07:27 all residents was a realistic practical possibility within the window of opportunity identified by dr. Lane dealing first of all with the viability of self evacuation can I just address please some matters that Professor
02:07:39 please some matters that Professor person has dealt with the point has been made that he had not at the time he prepared his report or gave oral evidence consider the firefighters evidence and clearly that will be
02:07:50 evidence and clearly that will be critical to any analysis by him but these are the points are in our respectful submission also importance some of the residents in the tower was simply not able to self evacuate by
02:08:02 simply not able to self evacuate by using the stairs because of for example disability those who would have been physically able to use the stairs would understandably be likely terrified about
02:08:13 understandably be likely terrified about the conditions they faced in the lobby and on the display and on the stairs in deciding whether to use the stairs as an escape route and so therefore with
02:08:24 as an escape route and so therefore with all respect to Professor purser the likelihood of there being an orderly procession of residents out of the building and the conditions they faced it is one that must be viewed with a
02:08:36 it is one that must be viewed with a degree of caution the stare capacity is simply that it is a capacity check it pays no regard to the realities of evacuation and the following features
02:08:49 evacuation and the following features are of course relevant poor visibility in the lobbies and stairs reducing the speed at which people could move the effect of extreme temperatures in excess of 150 degrees C with the moor lobbies
02:09:01 of 150 degrees C with the moor lobbies level 5 to levels 7 to 23 and the effect of toxic fumes and sensor irritants and gases in the smoke-filled obvious and stairs in addition there was no viable
02:09:13 stairs in addition there was no viable means of communicates we need to self evacuate it was dr. lanes opinion that intercom and the use of loud haters was not viable and insofar as you need at this phase sir to consider the issue of
02:09:25 this phase sir to consider the issue of the viability of self evacuation those are in our solution important considerations similarly insofar as you need to respectfully grapple with the issue of
02:09:36 respectfully grapple with the issue of what would have been different had stay-put been changed at about the time it is said it should matter about oh 126
02:09:47 it is said it should matter about oh 126 it's important to bear in mind the window of opportunity identified by dr. Lane which is from 58 minutes past midnight up to 140 or possibly Oh 200 in
02:10:02 midnight up to 140 or possibly Oh 200 in order to evacuate residents it would be necessary to have firefighting stairs and lifts which provided a safer air environment to reach the bridgehead
02:10:13 environment to reach the bridgehead located two floors below the fire floor the lobbies below the fire floor were required to provide a safe air environments to access the bridgehead and the stairs above the bridge had
02:10:25 and the stairs above the bridge had access by crew and be a would be required to provide 10 ability for crews to work including finding and connecting hoses to
02:10:32 hoses to mains and they're carrying down of any residents rescued we have set out a paragraphs 101 through to 108
02:10:45 paragraphs 101 through to 108 considerations that we say are relevant in that regard I'll just highlight a number of those if I may 2014 evacuating
02:10:57 number of those if I may 2014 evacuating but a conservative assumption of a minimum of one be a group per floor is for firefighters there for 20 floors requires a TBA where's now not all
02:11:11 requires a TBA where's now not all appliances would carry four firefighters who could actually access the interior to carry out the task 80 firefighters would require eight entry control boards
02:11:23 would require eight entry control boards and a number of supervisory staff according to telemetry Gator just before 2:00 a.m. there were 14 ba crews that had been committed it's 34 firefighters many of the
02:11:37 it's 34 firefighters many of the firefighters going up the tower at the early stage how to assist residents coming out other firefighters were outside the building dealing dealing with other matters for example hose management's residents who are
02:11:48 management's residents who are evacuating aerial platforms extinguishing fires calling by caused by falling debris and lookout for crews who are entering and leaving the building you have heard about the significant
02:12:00 you have heard about the significant communication difficulties in the tower now the highest number of firefighters in the tower at any one time was 28 ba where we asked the question even with
02:12:14 where we asked the question even with better radios with 80 firefighters in the tower some many of them seeking to use channels to communicate how would
02:12:25 use channels to communicate how would that be feasible if it was not feasible with 28 when also highlight these additional features if we may please four firefighters per floor may not have
02:12:37 four firefighters per floor may not have been adequate in any event that is because there may have been conditions on one or more floors that required a greater number of firefighters some firefighters would be
02:12:49 firefighters some firefighters would be needed for five for firefighting and evacuation and rescue there is the issue of how long it would take to commit that many firefighters into the building terms of briefing each crew logging on to ECB's communication checks there is
02:13:02 to ECB's communication checks there is the further issue of where the bridgehead would be located it would have to be located on the ground floor that would be the only area sufficiently large to accommodate that number of crew coming in and leaving and supervisory
02:13:15 coming in and leaving and supervisory staff we remind you of that which was addressed by mr. Seawind just at over 126 there were only six pumps at the farc V tower that would give a further
02:13:31 farc V tower that would give a further 14 minutes to Oh 140 if that has taken to the endpoint of the window to secure the requisite number of appliances firefighters and equipment and to deploy
02:13:43 firefighters and equipment and to deploy them into the tower with all that entailed to search and rescue on designated floors and with with the greatest respect we say that to suggest
02:13:55 greatest respect we say that to suggest that that is feasible is a judgment and an assessment with the wizard wisdom of hindsight and in our most respectful submission is not realistic dr. Lane herself recognized nor was that a total
02:14:08 herself recognized nor was that a total evacuation would require firefighters to have knocked on all the doors in addition to the number of firefighters that that would have required it
02:14:19 that that would have required it presupposes that the flats and laabh is not compromised by smokes and the firefighters can access those floors residents are awoken by the knocks on their doors and open their front doors and residents do not have mobility
02:14:30 and residents do not have mobility issues and are physically able to exit the building via the staircase if that were not so additional firefighters would be required and then please just
02:14:41 would be required and then please just these final three matters if I may sir after Oh 1:30 when the conditions in the tower deteriorated given the resources required at each floor and the very poor
02:14:52 required at each floor and the very poor conditions on those floors in our respectful submission at this stage it is possible to say that tragically it was simply never practicable to have been able to achieve
02:15:03 practicable to have been able to achieve a full evacuation of all residents from the tower within the window of opportunity for doing so secondly that some residents were able to self evacuate late in the night can be
02:15:15 evacuate late in the night can be attributed to the rapidly changing conditions in the tower over time affording certain residents on certain floors a better opportunity to escape and finally vesser coming back to what I
02:15:27 and finally vesser coming back to what I have described as the common denominator the condition of the tower it was put this way by group manager Welsh at the conclusion of his evidence we did not let you down the building let us all
02:15:38 let you down the building let us all down
02:15:51 at this point I'm going to invite mr. hochman to make the statement on behalf of our conic
02:16:25 yes when you're ready miss knocking thank you sir as you know we have submitted a lengthy and detailed written closing to which we
02:16:37 and detailed written closing to which we would invite the inquiry to pay close attention and so in this August statement I propose to summarize our written closing and in the course of
02:16:48 written closing and in the course of doing so to respond where necessary two points made by other Corps participants whether in writing or orally in my oral opening delivered to you several months
02:17:00 opening delivered to you several months ago I adopted the course of identifying ten key points points not Commandments for your consideration and I hope it will be helpful if I adopt the same
02:17:12 will be helpful if I adopt the same approach today before coming to the ten points I would like to reiterate once again our sympathy for all those affected by the fire at Grenville tower
02:17:23 affected by the fire at Grenville tower including of course the bereaved the survivors and the residents many of whom have now given evidence to you and I would include in this expression of
02:17:34 would include in this expression of sympathy and it's an expression of respect for every individual firefighter and other first responder who was deployed to the scene as well as those
02:17:46 deployed to the scene as well as those in the control and again you've heard evidence from many of these individuals a further preliminary comment that I would make is this we say in our written
02:17:58 would make is this we say in our written closing that it's already apparent that this inquiry is in many respects making history in part this is no doubt because of the scale of the tragedy which is being investigated the number of persons
02:18:11 being investigated the number of persons affected and involved and the complexity of some of the issues in addition it's because of the conscious effort which has been made to enable the survivors
02:18:22 has been made to enable the survivors residents and other local people to play their full part an effort which we unreservedly support and which has already achieved what I think was
02:18:33 already achieved what I think was described by one of the advocates for the BS RS as representing the gold standard now turning to the substantive points which
02:18:44 turning to the substantive points which I wish to make today these fall under two main headings some of my points relate to provisional evidential findings which we suggest it may be open
02:18:56 findings which we suggest it may be open to the inquiry to make even at this relatively early stage and in the context of your phase one report some of the points however to which I will come in the later part of this statement are
02:19:08 in the later part of this statement are points relating to the proper scope and approach applicable to your work at this stage I make no apology and this is my
02:19:20 stage I make no apology and this is my final preliminary observation I make no apology for selecting points which concern our clients this is not because we fail to appreciate the breadth of the
02:19:31 we fail to appreciate the breadth of the matters already covered by the evidence which you've heard but because it is only by seeing and taking fairly into account that evidence from the viewpoint
02:19:43 account that evidence from the viewpoint of each and every one of the core participants that you can hope to arrive at a true and just analysis of the material for you which I know you will be determined to do if we were to fail
02:19:56 be determined to do if we were to fail to present the specific perspective of a a psas of our Konica needs as it's known in this room then not only would we be
02:20:07 in this room then not only would we be letting our own clients down but we would be get we would be letting you down too or at least making your task a great deal harder so I come to my my
02:20:19 great deal harder so I come to my my first the first of my 10 points and this is to underline some of the information which you've received relating to the use of a CMP e cladding panels not just
02:20:32 use of a CMP e cladding panels not just at Grenville tower but more generally you now know that this kind of ACM panel has been in widespread use for many years in the United Kingdom and abroad
02:20:45 years in the United Kingdom and abroad even though we ourselves slide only a limited proportion of it the recent statement by the ministry noted that in the United Kingdom alone
02:20:57 noted that in the United Kingdom alone advice has been given to the owners of 457 high-rise buildings relating to the use of ACM cladding panels so it is
02:21:10 use of ACM cladding panels so it is clear that the use of such panels must have received regulatory approval up and down the country on many many occasions only in recent days has the UK
02:21:22 only in recent days has the UK government introduced regulations to control not the manufacture or sale of such panels but their use above a certain height I think to come into
02:21:33 certain height I think to come into force on the 21st of December of this year these obviously will be relevant matters when you proceed in phase 2 to
02:21:44 matters when you proceed in phase 2 to analyze where responsibility lies for the tragedy which occurred at Granville Tower
02:21:49 Tower however these vital background matters also have a bearing on the approach you should adopt to phase 1 and in particular we respectfully submit that
02:22:01 particular we respectfully submit that any comments about saying materials which you may make in your phase 1 report let alone specific findings if any should be limited to the
02:22:12 any should be limited to the circumstances at Brentford tower some of which I shall now go on to emphasize so that was the first of my 10 points the second point that I would
02:22:24 points the second point that I would like to make is that you already know and again I appreciate this will be a matter for fuller explanation exploration in phase 2 that as Professor
02:22:36 exploration in phase 2 that as Professor torero has told us I think it was line 2 275 in his report there have been many other cases of fires in residential
02:22:47 other cases of fires in residential buildings including high-rise buildings involving a CMP II where there has been no loss of life it was only the use of a
02:22:58 no loss of life it was only the use of a CMP
02:22:59 CMP II in combination with the other materials used in the refurbishment at Granville together with the configuration of those materials and the absence of other fire safety features in
02:23:13 absence of other fire safety features in the building that created the conditions for the catastrophe let me remind you please of what Professor torero stated in his oral evidence and these are
02:23:27 in his oral evidence and these are quotations from pages 177 and 179 of the PDF transcript he said some very large international fires with comparable fire
02:23:41 international fires with comparable fire spread have not resulted in the penetration of smoke and flames into the lobby or stairs in principle in those cases compartment ation is a very robust
02:23:54 cases compartment ation is a very robust way of giving a very significant amount of time for people to enter the stairs and be safe in the stair for an even longer period of time now the point has
02:24:05 longer period of time now the point has been well made that one should not attempt to draw easy comparison with other fires in other buildings whose detailed components may well be
02:24:16 detailed components may well be presently unknown but that is exactly the point that we seek to make it is the use of a CMP II in combination with other factors which has given rise to
02:24:29 other factors which has given rise to the problem and we ask you to bear this in mind throughout and to emphasize the point please in your phase 1 report I may add that no one could possibly
02:24:41 may add that no one could possibly suggest that our clients had a decision-making role in relation to any of these other factors in respect of Grenville Town
02:24:54 my next and third submission is that if the refurbishment of the interior window surrounds and the external envelope of
02:25:05 surrounds and the external envelope of the building had been carried out in a different way it would have been possible for the firefighters to extinguish the fire in flat 16 before
02:25:16 extinguish the fire in flat 16 before the fire even reached the cladding system in different ways all three of the inquiries relevant experts except that the materials with
02:25:27 experts except that the materials with which and the way in which the interior windows surrounds and the external envelope of the refurbished building were constructed meant that an internal
02:25:39 were constructed meant that an internal fire in one of the apartments would penetrate rapidly into the cladding system that is definitely the view of dr. Lane and of professor torero it is
02:25:51 dr. Lane and of professor torero it is also the view of professor Bisbee insofar as he acknowledges that the window surrounds were on any view one of the routes by which the exit of the fire
02:26:02 the routes by which the exit of the fire occurred even though wrongly as we have submitted in our written closing he considers that flame exiting an open window may also be relevant we note that
02:26:16 window may also be relevant we note that miss bar lies underneath renders bar wise in her oral comments agreed that professor Bisbee is unlikely to be right about this and you will find that at
02:26:27 about this and you will find that at page 56 line six of Monday's PDF transcript now it's worth reminding ourselves at this point as I developed
02:26:40 ourselves at this point as I developed this particular argument of a couple of matters of timing mr. Kirby Dee's first 999 call if I'm right was around
02:26:54 right was around 0:54 in other words 54 minute well as mr. Mansfield pointed out a fire extinguisher a simple fire extinguisher in his hands would have made a big
02:27:07 in his hands would have made a big difference to the outcome but in any event the firefighters themselves were in the flat not long after five past one seven minutes past one I think and if the
02:27:20 minutes past one I think and if the window surrounds had been capable of maintaining compartment ation as they ought to have done again the course of subsequent events in terms of the
02:27:31 subsequent events in terms of the far-reaching the cladding system as a whole would have been very different remember also please and this is a
02:27:42 remember also please and this is a further point within the same theme that the use of PAI our insulation immediately outside the windows structures a material which has a low
02:27:54 structures a material which has a low thermal inertia and therefore catches fire relatively quickly meant that not only did the fire exit from the flat much more quickly than anyone would have
02:28:05 much more quickly than anyone would have expected but it contributed to an increase in temperature within the cladding system cavity they're put there by providing optimum conditions for the
02:28:16 by providing optimum conditions for the ACM PE panels to catch fire this sequence of events was entirely avoidable if a different approach to the refurbishment had been adopted
02:28:28 refurbishment had been adopted irrespective of the type of rain screen paneling which was thereafter superimposed now in that submission again we are supported by the closing
02:28:41 again we are supported by the closing the written closing statement of mr. Freedman was bar wise and their colleagues who at their paragraph 2.46 and I quote make the following point and
02:28:53 and I quote make the following point and it's exactly the point that I've just made had the insulation used been of limited combust ability this would have reduced the speed with which it burn
02:29:05 reduced the speed with which it burn particularly at the outset and this is the key part of it potentially enabling the lfb to extinguish the fire before it
02:29:16 the lfb to extinguish the fire before it took hold in the facade and or enabling occupants to evacuate in time and that point was confirmed orally diamonds bar wise on Monday at page 72 line seven and
02:29:34 wise on Monday at page 72 line seven and if that point about the insulation is valid as we submit that it is then it must follow that the same point can equally correctly be made not only in
02:29:45 equally correctly be made not only in relation to the insulation which was attached to the exterior of the building but in relation to the components of the windows surrounds to which I referred a little earlier and this point in general
02:29:59 little earlier and this point in general this Third Point is consistent with point two which I made previously namely that it was only the use of the ACM PE panels in combination with other
02:30:12 panels in combination with other components that gave rise to a risk to health and safety the point is obvious and we submit irrefutable now my next point my fourth
02:30:25 irrefutable now my next point my fourth point is that if certain internal features of the building internal features had been differently designed and constructed then the fire would have
02:30:36 and constructed then the fire would have penetrated the building much less rapidly and thus all or at least much of the tragic loss of life would have been spared and by internal features of the
02:30:47 spared and by internal features of the building I have in mind among other factors the nature of the purported fire doors the nature of the ventilation system and the absence of sprinklers
02:30:58 system and the absence of sprinklers factors such as these had a key influence upon the penetration of the fire from each of the individual flats into other parts of the building a
02:31:11 into other parts of the building a comparable point could be made in relation once again to the design and construction of the wind surrounds which had a key influence on the speed with which the external fire
02:31:23 the speed with which the external fire penetrated back into the interior of the girl in essence as many of the experts have highlighted there was a fundamental failure of compartment ation a key issue
02:31:37 failure of compartment ation a key issue a key assumption on which high-rise fire safety strategy is predicated now move
02:31:50 safety strategy is predicated now move on to my fifth point which is to make a comment arising from the evidence of some of the members of the fire service
02:32:03 some of the members of the fire service it's clear from that evidence that the issue of compartment ation was one to which many if not all of the farc fire fighters attached the greatest
02:32:14 fire fighters attached the greatest importance in the evidence given by the senior officers of the London Fire Brigade
02:32:19 Brigade they explained that firefighters did assume in advance of the fire and moreover considered that they were entitled to assume that the regulatory
02:32:30 entitled to assume that the regulatory system would ensure that compartment ation would be maintained making it unlikely that a fire in a particular apartment would penetrate to the outer
02:32:42 apartment would penetrate to the outer facade of the external envelope they stressed that they had assumed also and were entitled to assume that a fire
02:32:53 were entitled to assume that a fire affecting the external envelope would not be expected to penetrate back into the building and spread internally again in breach of compartment ation they
02:33:05 in breach of compartment ation they clearly believed that in the case of Grenville tower breach of compartment ation both externally and internally had occurred and that this was not only
02:33:16 occurred and that this was not only unforeseen but was indeed a bigger issue for them than the fire spread on the external
02:33:24 external envelope now the concluding comment that I would make about these points is that if the firefighters were entitled to
02:33:36 if the firefighters were entitled to make or did reasonably make such assumptions as to the level of compartment ation which would be maintained within this high-rise block
02:33:48 maintained within this high-rise block then it would follow with it not that the supplier of a component part of one single component part of the external
02:33:59 single component part of the external envelope would surely have been entitled to make a similar assumption particularly if after such supply that supplier was not involved in any of the
02:34:12 supplier was not involved in any of the subsequent refurbishment and construction work now my next point my sixth point my sixth and seventh points
02:34:23 sixth point my sixth and seventh points in fact are shorter and they are these firstly the sixth point just to identify or to isolate and say a word or two about the insulation it is our
02:34:36 about the insulation it is our submission that the external spread of the flame was substantially exacerbated by combining a CMP II with combustible PIR insulation without any or without
02:34:50 PIR insulation without any or without any horizontal or indeed vertical bands of non combustible material to limit spread the PIR insulation ensured that the fire would spread to new portions of
02:35:02 the fire would spread to new portions of the building and then ignite the ACM PE the absence of breaks in the continuity of combustible materials ensured that the fire had a clear path to spread
02:35:15 the fire had a clear path to spread across the entire facade and my seventh point which relates to the white value glaze panels which were also capable of catching light quickly and of
02:35:27 catching light quickly and of contributing to the spread of fire across all the facades of the building the use of these panels is an example of the design choice just
02:35:39 is an example of the design choice just as the the choice that I criticized in my previous point in other words the failure to ensure that there were bands of non combustible material to limit the
02:35:51 of non combustible material to limit the fire spread instead the use of Al you glaze panels between the windows self-evidently created a path by which the fire could spread and did spread
02:36:03 the fire could spread and did spread from one level to the next so I move to my eighth point the tragedy at rental
02:36:15 my eighth point the tragedy at rental Tower shows the awful consequences which can arise when combustible materials are used in a particular combination and configured in a particular manner when
02:36:28 configured in a particular manner when compartment ation is significantly compromised by refurbishment works and when there is a lack of any or any sufficient protective measures such as
02:36:39 sufficient protective measures such as sprinklers however that does not show that the use of ACM panels in itself would have given rise to a risk to
02:36:50 would have given rise to a risk to health and safety under the applicable regulatory regime there was no prohibition on the use of this material and it has been widely used whether it
02:37:01 and it has been widely used whether it could be appropriately used and if so to what extent and in what manner would have been a matter for assessment taking into account all the features of the
02:37:12 into account all the features of the building including its component materials and including the incident and this is important of active and passive fire prevention measures and we do
02:37:25 fire prevention measures and we do suggest that it's likely that if there were sections where the continuous ACM PE panel had been interrupted either by non PE panels or different design
02:37:37 non PE panels or different design features such that the continuity of the PE was broken the fire would have been slowed or interrupted although the combustible insulation and
02:37:49 although the combustible insulation and perhaps the non-existent or ineffective cavity barriers would have allowed the fire to propagate in any event it's also possible that had the white panels not
02:38:00 possible that had the white panels not being combustible there would have been no vertical spread between the spandrels as there would have been neither combustible insulation nor combustible panels in the window line if a non
02:38:14 panels in the window line if a non combustible band had also been present on the columns it is likely that fire spread would have been dramatically slowed and possibly prevented now
02:38:25 slowed and possibly prevented now similar points and I just need to develop this particular argument a little further similar points can be made in respect of the architectural crown again a design choice by others
02:38:38 crown again a design choice by others which we accept may have some significance though in our written closing as you see we've explained why the significance of the crown in relation to fire spread may have been
02:38:50 relation to fire spread may have been somewhat overstated and equally the significance of the ACM PE panels forming part of the crown may itself have been overstated given the extensive
02:39:01 have been overstated given the extensive presence once again of combustible insulation and we'd refer you please to paragraphs 85 to 92 of our written closing in which
02:39:13 85 to 92 of our written closing in which these points are covered in detail let me summarize very briefly the points that we make in those paragraphs firstly as regards the structure of the crown as
02:39:26 as regards the structure of the crown as we know this comprised a series of vertical ACM PE fins or louvers and below these was aluminium coping with a layer of insulation underneath as dr.
02:39:39 layer of insulation underneath as dr. Lane's figure ten point four seven with which we're all familiar makes clear now we explained in paragraphs 86 and 88 of
02:39:50 we explained in paragraphs 86 and 88 of our
02:39:51 our that there is clear evidence and this I think is a point that has not yet been sufficiently noted that some of these louvers were unaffected or at any rate
02:40:04 louvers were unaffected or at any rate not fully affected by the fire and we submitted in our written closing that this showed that the fire on those panels was not self-sustaining without
02:40:15 panels was not self-sustaining without the heat retention of backing insulation or in other words that it was the insulation which was significant in driving the spread of the fire and we
02:40:26 driving the spread of the fire and we argued and continued to argue that that is supported by some images produced by Professor Bisbee himself which show undamaged ACM louvers which he has
02:40:40 undamaged ACM louvers which he has annotated section of uninvolved architectural crown uninvolved architectural crown those are I think figures 142 and 139 and this approach is
02:40:58 figures 142 and 139 and this approach is supported also by the evidence of dr. Lane in her paragraphs 10 8 20 and 10 821 and let me quote briefly from those
02:41:12 821 and let me quote briefly from those paragraphs she says that the far spread around the Clapp the crown of the cladding system would have been supported in the presence of combustible cladding panels
02:41:24 presence of combustible cladding panels and insulation the insulation wrapping over the top of the roof edge and she says that the cladding fins had no
02:41:35 says that the cladding fins had no combustible insulation behind them and they were not continuous and therefore in her view it is currently unclear to what extent the burning of the fins may
02:41:48 what extent the burning of the fins may have contributed to fire spread at roof level and those points we suggest do emerge clearly from the evidence that you've heard and which we've analyzed as
02:42:01 you've heard and which we've analyzed as I say in greater detail in our written closing
02:42:03 closing despite some some anxieties which we had to express in our written closing as to the way in which the matter was dealt with in questioning now I come to my
02:42:16 with in questioning now I come to my final two points points 9 and 10 and as I foreshadowed earlier these two points relate not so much to the evidence that you've heard but as to the approach
02:42:28 you've heard but as to the approach which we respectfully suggest you might wish to adopt the first point concerns the scope of phase 1 as we have understood it and we hope that in
02:42:40 understood it and we hope that in preparing your phase 1 report you will throughout bear in mind the following firstly in his statement at the procedural hearing on the 11th of
02:42:51 procedural hearing on the 11th of December 2017 your counsel made clear that the aim is that phase 1 is a purely fact-finding exercise and he identified
02:43:02 fact-finding exercise and he identified the relevant issues that statement was followed through in his description of the scope of the phase 1 expert evidence in response following that hearing you
02:43:13 in response following that hearing you stated that phase 1 would concentrate on what happened on the night of the 14th of June 2017 and would seek to establish where and how the fire occurred how it
02:43:25 where and how the fire occurred how it spread so rapidly and how the interior of the building became progressively affected you did of course stress the need for a degree of flexibility in
02:43:36 need for a degree of flexibility in relation to scope at the procedural hearing in March 2018 it was said that dr. Lane might express a preliminary view about certain aspects of compliance
02:43:48 view about certain aspects of compliance but would not investigate how any instances of non-compliance came about being matters that would be dealt with in phase 2 as regards section 4 in the
02:44:00 in phase 2 as regards section 4 in the list of issues in which compliance is raised at no stage has it been suggested that phase 1 would go beyond section 4 be dealing factually with the design
02:44:13 be dealing factually with the design manufacture composition and Method fixing of the cladding finally in his statement to the inquiry on the 4th of June 2018 your council repeated that the
02:44:25 June 2018 your council repeated that the focus of phase 1 would be on the events of the night of the 14th of June 2017 and in particular the state of the building at the time of the fire so we
02:44:37 building at the time of the fire so we do feel entitled to submit and do submit that issues relating to compliance in relation to the cladding system as well as sub issues such as test results and
02:44:49 as sub issues such as test results and certificates ah and should be he matters for phase 2 and that he would be inappropriate for the inquiry to draw conclusions even provisional in relation
02:45:01 conclusions even provisional in relation to these matters and that submission we suggest is supported when you look at the inquiries letter to Corps participants dated the 30th of July 2018
02:45:12 participants dated the 30th of July 2018 in which it was expressly stated that dr. lanes appendix F dealing with testing and certificates and various compliance matters dealt with by
02:45:23 compliance matters dealt with by Professor torero would be matters for phase 2 perhaps it is for all these reasons that as we understand it the inquiry has not yet
02:45:35 understand it the inquiry has not yet heard evidence as to how compliance in relation to the refurbishment was actually assessed during and following the refurbishment by the wreck by the
02:45:46 the refurbishment by the wreck by the relevant regulatory authorities such as Building Control and other relevant parties in the absence of such information being explored any conclusion as to Clark compliance would
02:45:59 conclusion as to Clark compliance would plainly and on any view be premature moreover it is to be recollected the the inquiry has not yet heard from Colin Todd who was instructed to report
02:46:11 Todd who was instructed to report and has reported specifically on regulatory issues now in the light of what I've been saying we do respectfully
02:46:22 what I've been saying we do respectfully submit that he was not altogether helpful for the suggestion to be made that in asking the inquiry to consider compliance at the stage at which the
02:46:35 compliance at the stage at which the inquiry itself quite rightly we say had promised to do that core participants were kicking the can down the road there should be no criticism of anyone
02:46:47 there should be no criticism of anyone for requesting that stated procedures should be adhered to and not contravene these comments have particular relevance
02:46:58 these comments have particular relevance in the context of one or two of the arguments that have been placed before you as to whether or not there was indeed compliance with the regulatory regime we were vigorously criticized for
02:47:11 regime we were vigorously criticized for a change of position in closing and for failing to recognize the alleged non-compliance of our product this criticism we say was to use I hope a
02:47:23 criticism we say was to use I hope a moderate expression misplaced for the avoidance of doubt we stand by the content of our written and oral opening statements indeed we invite your close
02:47:34 statements indeed we invite your close attention to them please and like others we reserve our position as to whether the core of an ACM panel constitutes in the technical term Philip we will be
02:47:48 the technical term Philip we will be submitting however in phase two that the inquiry would be wrong to find that a CMP itself was necessarily non-compliant with the regime we've explained
02:48:02 with the regime we've explained repeatedly in our phase 1 written opening and closing the four recognized routes to compliance in approved document b two of which two of which dr.
02:48:17 document b two of which two of which dr. Lane has expressly decided not to consider for the purposes phase 1 including importantly the option of holistic fire engineering assessment
02:48:28 of holistic fire engineering assessment in accordance with industry practice and we respectfully note that counsel who criticized us for inconsistency herself
02:48:39 criticized us for inconsistency herself recognizes for the first time in closing that these four groups exist once this is acknowledged it's impossible to argue that a CMP was itself necessarily
02:48:52 that a CMP was itself necessarily non-compliant whatever that expression may mean the position in any individual case would depend on assessing the combination of materials and all other
02:49:04 combination of materials and all other relevant considerations as our opening statement we do note that in her oral
02:49:19 statement we do note that in her oral closing and it's in the PDF transcript page 66 line 19 that ms bar wise told you that in phase 2 and please note that
02:49:34 you that in phase 2 and please note that it was she who said in phase 2 she will submit that the core of the panel's should have been of limited combustibility the difficulty with that
02:49:46 combustibility the difficulty with that argument is that not only is there continuing debate as to whether the core was filler for the purpose of paragraph 12 point 7 a proposition which dr. Lane
02:49:58 12 point 7 a proposition which dr. Lane at least vigorously disputes but in any event there are at least three other routes to compliance any argument based on an isolated and indisputably
02:50:10 on an isolated and indisputably ambiguous element in the regulatory regime a regime which by common consent is going to need serious reform going forward is surely as we have submitted
02:50:22 forward is surely as we have submitted for phase two and so it is essentially for these reasons that we consider that you were absolutely right to delineate the scope of phase 1 in the
02:50:35 to delineate the scope of phase 1 in the way that you did and to declare unambiguously that matters relating to the testing and certification of individual products simply do not arise
02:50:46 individual products simply do not arise at this stage that at slightly greater length was my ninth point and I come finally to my tenth point which is
02:50:58 finally to my tenth point which is shorter and the echos comments made by many other core participants in other words to stress what must as we submit be the relatively provisional nature of
02:51:12 be the relatively provisional nature of such conclusions as you feel you can make in Phase one all the experts have very sensibly caveated their views by
02:51:24 very sensibly caveated their views by repeated references to the need for further experimentation and analysis there remains does there not a good deal of primary empirical evidence yet to be
02:51:38 of primary empirical evidence yet to be gathered in not least material held by the Metropolitan Police there would we suggest be the risk of significant inaccuracy and indeed of grave injustice
02:51:51 inaccuracy and indeed of grave injustice if you expressed firm and unalterable conclusions in relation to scientific and expert matters which have been brought but briefly covered in the oral
02:52:03 brought but briefly covered in the oral evidence without the opportunity for cross-examination or challenge other than through the submitting submission of written questions not all of which perhaps understandably were fully
02:52:15 perhaps understandably were fully pursued and that point is reinforced by the helpful letter from the inquiry received earlier this week concerning the possibility of yet further material
02:52:26 the possibility of yet further material coming to light for example from the Metropolitan Police Service and whilst we note that there may be the opportunity to make further phased repetitions we suggest that it is much
02:52:38 repetitions we suggest that it is much more likely that any further material will be relevant instead to Phase two with that tenth and final point we trust faithfully recorded as
02:52:51 point we trust faithfully recorded as always though perhaps not on tablets of stone we leave the matter in your hands thank you very much mr. Hoffman
02:53:04 well now we've we've made very good timing and I can see that mr. Leonard is on his way too well I was just wondering mr. Leonard
02:53:16 well I was just wondering mr. Leonard whether you feel sorry you take your place before I told you it's some trepidation yes I was just wondering whether you feel comfortable in finishing by the usual art or whether we
02:53:28 finishing by the usual art or whether we would do better than ever a break at this point and resume after lunch the latest I don't want you to feel rushed I went and there are things I need to deal
02:53:40 went and there are things I need to deal with after you have finished your statement they're going to gauge where the wind is blowing yeah I have to say huh am i for my own part I can be finished by 5:00 past 1:00 I'd sort of
02:53:52 finished by 5:00 past 1:00 I'd sort of negotiated with the shorthand writers if that happened it would still be possible and that would clear this afternoon for all of us to think about the way forward yeah if we need right well you've carry on
02:54:02 on I may have to trespass on people's patience a little bit after you finish but I hope they'll forgive me if I do that indeed sir right well when you're ready you yes so thank you on behalf of
02:54:14 ready you yes so thank you on behalf of CSH associates Limited for allowing us this further opportunity to address you and all submission we've supplied a written submission that we know you've taken account of but first of all may I
02:54:26 taken account of but first of all may I just say as others have that the courage and fortitude shown by bereaved survivors and relatives when giving evidence has been truly remarkable and the bravery and commitment of the
02:54:37 the bravery and commitment of the emergency services who attended is similarly worthy of recognition CS Stokes remains committed to assisting the public enquiry as best it can by
02:54:49 the public enquiry as best it can by merrily with the fire safety order and fire risk assessments and to that end has provided disclosure to your team suggested questions some of which have been asked and provided a lengthy
02:55:01 been asked and provided a lengthy witness statement in response to the rule 9 request and my submissions today will focus on the following firstly topics for determination by you at phase
02:55:12 topics for determination by you at phase 1 secondly some more comment about stay put thirdly it's a more comment about GRA 3.2 fourthly some
02:55:24 comment about GRA 3.2 fourthly some inferences of fact we invite you to consider and fifthly some conclusions as far as topics for phase one and concerned I bear very much in mind what
02:55:35 concerned I bear very much in mind what we've literally just heard from Elena and mr. Hoffmann Queen's Counsel who takes a slightly different view and all the submission that as I apprehend it and I think I'm the last will most every
02:55:46 and I think I'm the last will most every other person addressing you orally has taken namely scope and the issue of compliance I agree with him that as at the 4th of June 2018 and in a letter
02:55:58 the 4th of June 2018 and in a letter following that up on the 30th of July core participants about expert evidence were invited to the issues that were to be determined at phase one as we
02:56:09 be determined at phase one as we perceive it none of the questions identified on the 4th of June refer actually to compliance with building regulations even compliance of the
02:56:20 regulations even compliance of the cladding system phase 1 has not formally been expanded and we haven't heard from your team as part of closing submissions but it is always remain flexible a
02:56:31 but it is always remain flexible a number of core participants the BS ARS wrote biochemist in Chelsea and others have said and indeed asked the compliance of the classic cladding
02:56:42 compliance of the classic cladding system be addressed as we said in opening CS Stokes does not dispute the proposition perhaps even more now reinforced after months of evidence that
02:56:55 reinforced after months of evidence that the external walls of Grenville tower did not adequately resist the spread of fire and that thus it was in breach of the functional requirement of the building regulations and we have no
02:57:06 building regulations and we have no objection to you addressing that issue directly in your phase 1 report however if you do think it appropriate to go that far
02:57:16 that far may we invite you to say that no other issue of compliance should be determined at this stage by way of example only a degree of evidence and comment is made
02:57:28 a degree of evidence and comment is made about the front doors to the flats sir we have already supplied specification for the 2011 and 2012 flat front door work and relevant documents by way of
02:57:41 work and relevant documents by way of annex to disclosure and a witness statement and we've referred to in our witness statement these documents identified the doors that were to be obtained how they and what they were to
02:57:53 obtained how they and what they were to be fitted with and how it was to be done including details of a survey done by a third party of those doors following the work that had been completed it was
02:58:05 work that had been completed it was apparent that dr. Lane had not seen that material but we're not sure why but any discussion we respectfully suggest about compliance in relation to those doors ought to include consideration of that
02:58:17 ought to include consideration of that material at the very least some evidence was given about testing requirements of those flat doors that seems to us possibly out of step with what we suspect to be the relevant British
02:58:29 suspect to be the relevant British standard and there may be an inconsistency between criticism of the lobby doors and performance on the night further evaluation sir as you know the
02:58:40 further evaluation sir as you know the lift operation and ventilation system is also under way so that by conclusion we have no difficulty with a compliance finding being made in the cumulation to the cladding system if you think it
02:58:52 the cladding system if you think it appropriate but would avoid it we'll invite you to avoid making other findings in relation to plans not compliance on the other issues stay put
02:59:05 despite it still possibly being viewed as a misnomer by some stay put is an evacuation strategy and is referred to
02:59:17 evacuation strategy and is referred to as such in the local government guidance document that you've heard with reference being made to on page 180 and he is also described in that way in the
02:59:28 he is also described in that way in the London Fire Brigades own materials if he will forgive me for saying so contrary to what mr. Mansfield QC said yesterday get out and stay out was not the policy
02:59:40 get out and stay out was not the policy in the tower prior to the refurbishment CS states was involved in the building as early as 2009 and at that stage it was stay put and it has continued to be
02:59:53 was stay put and it has continued to be that way ever since CS Stokes cannot presently date the notice that you were reminded of yesterday it may be many years old but more importantly it may
03:00:06 years old but more importantly it may only relate to the common parts and to someone who discovers fire in those common parts rather than to those otherwise in the building not immediately affected and to that extent
03:00:17 immediately affected and to that extent it is consistent with that part of the stay-put strategy that existed we can however say with certainty that for the residential parts of the building stay
03:00:29 residential parts of the building stay put
03:00:29 put was the strategy in place sincere states involved in 2009 and in all likelihood for the reasons that you've heard ever since the building was constructed
03:00:41 since the building was constructed second point I'd like to make about make about stay put is this stay put is advice it is not an order however it is important advice desperately important
03:00:54 important advice desperately important advice both to be given and received because for anyone caught up in a fire it may represent the answer to the key question what do I do to keep safe the
03:01:09 question what do I do to keep safe the advice is leave if the flat is affected by fire or even if it is not leave the flat if you want to otherwise
03:01:20 leave the flat if you want to otherwise the advice is to remain in your dwelling however insofar as it is relevant to firefighting strategy it is not a binary
03:01:31 firefighting strategy it is not a binary position in other words stay where you are
03:01:34 are or self evacuate for example if the advice given were wait where you are you're going to be rescued that does not in our submission represent an
03:01:46 in our submission represent an abandonment of the stay-put advice per se in the sense that it is not inviting self evacuation conversely abandoning
03:01:58 self evacuation conversely abandoning stay put is or would be saying to someone requiring fire survival guidance now you are best advised to self evacuate so the key to understanding
03:02:09 evacuate so the key to understanding this distinction in our respectful submission is to understand that changing stay put advice is to require or advise self evacuation as others have
03:02:20 or advise self evacuation as others have already said stay put is predicated on the basis that calm fermentation is maintained and that is supported by the building regulations as well as approved
03:02:31 building regulations as well as approved document b whichever expert view of compartment ation and breeches to be taken the LF be appeared to anticipate is foreseeable fire spreading to a
03:02:43 is foreseeable fire spreading to a compartment above the fire floor as a matter of practice that's not because fire spread has been promoted by the external walls as in this case but
03:02:55 external walls as in this case but because it may pass through a window to the flat above sometimes referred to as the calendar effect now in practice therefore in the context of strategy
03:03:06 therefore in the context of strategy compartment ation breach is not cut and dried to the far leaving one flat necessarily and entering another likewise if a fire up fighter opens the
03:03:18 likewise if a fire up fighter opens the main front door to flat just to fight a fire that's within it theoretically compartment ation is automatically breached but not significantly so the same might be said
03:03:29 same might be said opening a lobby door so as to allow a hose through the firefighting activity thus it is the extent and the effect of the breach of compartment ation which is important in the context of strategy not
03:03:42 important in the context of strategy not whether a breach has occurred per se may I repeat what others have said on the night of the fire the lfb were fighting a fire which they
03:03:53 the lfb were fighting a fire which they never anticipated having to fight and were giving FSG fire survival guidance on an unprecedented scale the towers active and passive fire safety measures
03:04:04 active and passive fire safety measures were being asked to address a fire they had never been designed or installed to address we are however conscious that despite multiple criticisms of the fire
03:04:16 despite multiple criticisms of the fire fighting tactics deployed on the night you are yet to hear from mr. McGurk your firefighting expert and so in our submission it is difficult to say that
03:04:27 submission it is difficult to say that definitive conclusions on firefighting would be anything other than premature however if the firefighting strategy did
03:04:38 however if the firefighting strategy did need to be changed and this may be something that mr. ghertner Girt needs to look at then that change could have been serviced to increase the emphasis on a structured and assisted evacuation
03:04:51 on a structured and assisted evacuation of the building that did not rely on a call being received from a particular flat but affected a structured and assisted evacuation of the building floor by floor
03:05:02 floor by floor in other words whereas the plan appears to have been rooted in reacting to SFG calls rather than proactively seeking
03:05:14 calls rather than proactively seeking the residents out there may be some grounds for believing the latter should have been the focus earlier but again it may be too early to make that final
03:05:25 may be too early to make that final determination what is interesting and of note however is that GRA 3.2 on page 29 foresaw that it as a matter for the
03:05:36 foresaw that it as a matter for the incident commander to consider advising callers to be and I quote guided from there
03:05:43 there property by the firefighters was an option that is not to say that there was reliance on the lfb to be responsible for evacuation in advance as a matter of
03:05:54 for evacuation in advance as a matter of course it identifies what may become necessary depending on the circumstances in paragraph 7.58 of lfb pn6 3:3 says
03:06:08 in paragraph 7.58 of lfb pn6 3:3 says something similar but if that was the case if we were moving to an assistant evacuation that would not have required the residents to leave the flats and try
03:06:20 the residents to leave the flats and try and make it on their own it would have been an assisted evacuation from where they were and so we invite you not to underestimate the fact that those
03:06:31 underestimate the fact that those changing the advice to self evacuation would have known that it carried profound risk to those being told to evacuate the reasons that you have been
03:06:42 evacuate the reasons that you have been explored in evidence however we still maintain that either stay put in or self evacuation out was not the only binary
03:06:54 evacuation out was not the only binary choice and if that strategy had been changed a little earlier perhaps the emphasis on equipment might have been different and by that I mean obtaining
03:07:05 different and by that I mean obtaining as much extent extended duration breathing apparatus as possible as an absolute priority establishing a means of communication might have been more appropriate and to that end we do invite
03:07:16 appropriate and to that end we do invite you to consider the intercom this was raised not by CA States because it was said to be an existing fire safety installation but because at the very
03:07:27 installation but because at the very least it represented a chance for all of the flats to be contacted and that does not appear to have been considered interestingly you may also note though on page 49 of GRA 3.2 the question of an
03:07:40 on page 49 of GRA 3.2 the question of an income as a intercom forgive me as a control measure is specifically referred to next GRA 3.2 which has been extensively referred to in evidence and
03:07:52 extensively referred to in evidence and submissions it's a national policy document from which the local policy documents should as we understand it be developed thus it should feed into for example lfb 63 lfb
03:08:06 should feed into for example lfb 63 lfb 800 and others and thence ultimately into the ORD document for each high-rise building operationally as I perceive it
03:08:17 building operationally as I perceive it it is not disputed that the lfb was required to have an operational contingency plan in the event that stay-put became untenable the
03:08:28 stay-put became untenable the contingency plan would have been one that took over essentially strategically from stay put and therefore needed to be developed in accordance with that document there is no doubt that through
03:08:42 document there is no doubt that through a process of seven 2d visits the lfb are required to have and as a matter of fact did have every opportunity to visit the tower and formulate such a plan crews
03:08:54 tower and formulate such a plan crews were regularly on site and had access not only to the lifts themselves but also the ventilation system what is not obvious and immediately clear is why the Geo are a three point two requirement
03:09:07 Geo are a three point two requirement for a contingency plan did not find its way into lfb 633 what you will note however is that the ORD document itself for the tower has a space in it for
03:09:20 for the tower has a space in it for operational contingency plan that was not actually completed my LAN friend mr. C word has referred to a passage of
03:09:31 C word has referred to a passage of mistakes by risk assessments and it is true to say that in his fire risk assessments for 2010 12 14 and both in 2016 all observed that the fire service
03:09:43 2016 all observed that the fire service or TMO employees would arrange for a general evacuation the building if appropriate as was made clear in my opening the FRS of the tier most of the provide to the LFE as they wished that
03:09:55 provide to the LFE as they wished that we have absolutely no doubt as phase to disclosure will show that the TRO 2012 f ra
03:10:02 ra was definitely supplied to the lfb without any criticism or concern raised quite the opposite and we are fairly confident that the June 2016 1 @ was as
03:10:13 confident that the June 2016 1 @ was as well but no doubt we can return to that in due course reference to general evacuation in the fr a we respectfully suggest it's entirely consistent with a requirement for a contingency plan in
03:10:26 requirement for a contingency plan in GRA 3.2 and in lfb policy 7.4 6 may I turned to some inferences of fact to be
03:10:37 turned to some inferences of fact to be drawn unfortunately looking at the time there aren't very many of them and we've set some out in our written submission and they are profound but simple ones to be drawn from some simple but important
03:10:48 be drawn from some simple but important propositions of fat firstly the firefighters the first firefighters were in flat 16 at or about o 1:07 on the
03:10:59 in flat 16 at or about o 1:07 on the night of the fire shortly thereafter fire escape flat 16 through the fan vent an open window or via the uPVC surround
03:11:10 an open window or via the uPVC surround and ignited the cladding system the cladding system did not just come into contact with flame as it might have done and resist fire spread as it should have
03:11:23 and resist fire spread as it should have done it ignited if it had not so ignited it is blindingly obvious to state that the fire would not have spread in the way it did however as has been
03:11:35 way it did however as has been emphasized this morning most importantly in this context the original internal fire in the kitchen was extinguished by or about a 1:21 that morning the
03:11:50 or about a 1:21 that morning the inference is to draw from those facts we respectfully suggest can be these compartment ation would never have been compromised by the original fire in a flat 16 with a properly compliant
03:12:03 flat 16 with a properly compliant cladding system it would have resisted the spread of fire rather than ignited and promoted it there is no reason to suppose that if the cladding
03:12:14 suppose that if the cladding system had not ignited say stay put as a safety measure or strategy would have been compromised there is no reason to suppose that if the cladding had not
03:12:27 suppose that if the cladding had not ignited relevant active and/or passive fire measures in the tower would have been gauged at all let alone compromised outside flat 16 the firefighters would
03:12:40 outside flat 16 the firefighters would have extinguished the fire in the way they described ensure there was no spread to the flat path or deal with it if it had and addressed the aftermath to the extent they needed to in all
03:12:52 the extent they needed to in all likelihood so we say relevant active and passive fire measures present in the building would have coped as intended with all fire and smoke generated by the
03:13:03 with all fire and smoke generated by the original file bio 121 and as I said by has been said by others therefore key to this whole process of spread is the ignition rather than resistance of the
03:13:16 ignition rather than resistance of the cladding system and not the active failure of active and passive fire measures in the town by way of conclusion even if a contingency plan
03:13:30 conclusion even if a contingency plan had been formulated by the London Fire Brigade we respectfully suggest that such a plan would never have contemplated a need to invoke you ate the entire building with some urgency by
03:13:43 the entire building with some urgency by a 126 if that is a conclusion you come to they might have identified how it might have been achieved in the longer term but not within that timescale
03:13:55 term but not within that timescale despite cladding being referred to in gr 3.2 and despite evidence about previous high-rise fires in the immediate aftermath of a refurbishment involving
03:14:07 aftermath of a refurbishment involving multiple expert contractors a fire engineer and approving approval from Building Control to which the London Fire Brigade are party to their ends fire engineering department the LF be we
03:14:19 fire engineering department the LF be we venture suggests would never have contemplated the fire spreading so quickly
03:14:24 quickly or is so extensively for the reasons it did
03:14:27 did if the lfb had contemplated that for such far spread and the only conclusion was the need to be able to effect an all but immediate complete evacuation of the
03:14:38 but immediate complete evacuation of the building stay put as a policy is highly unlikely to have been in place at all and the active and passive fire safety measures measures in the building are unlikely to being thought capable of
03:14:50 unlikely to being thought capable of supporting such a need this feeds in to dr. lanes reasoning that the building should not have been occupied or handed over in the condition it was post
03:15:01 over in the condition it was post refurbishment her conclusion was that on the basis of that construction there were no active or passive fire safety measures that could have addressed or
03:15:13 measures that could have addressed or reduced the risk of harm posed by the cladding as constructed as fire risk Assessor we agree however suffice it to say and we have said it in writing that
03:15:26 say and we have said it in writing that if a building is passed as compliant by Building Control that should be capable of being taken to mean that the functional requirements of b4 was
03:15:38 functional requirements of b4 was satisfied and that a route for compliance with approved document b had properly achieved and thus that the cladding would not represent a risk to
03:15:49 cladding would not represent a risk to the health and safety of those that live there but those are matters for you to investigate at phase 2 unless I consist you further there's no submissions thank you very much indeed
03:16:07 mr. minute can I just check there's nothing you wish to say in response to any of those statements no mr. chairman there isn't thank you thank you very much well that brings us to the end of the opening statements and also to the
03:16:21 the opening statements and also to the end of this these phase-one hearings I hope I'll be forgiving for trespassing a little further on your good nature and out of the transcribers if I take this
03:16:33 out of the transcribers if I take this opportunity to close the proceedings with a few remarks because before we all leave I think this is a good time to take stock for a moment or two of what
03:16:44 take stock for a moment or two of what the inquiry has done so far and what it will be doing over the coming months in phase one we're seeking to establish in some detail what happened at Grenville
03:16:57 some detail what happened at Grenville Tarr on the 14th of June 2017 so that in phase two we can focus our attention on the critical circumstances and decisions
03:17:08 the critical circumstances and decisions which enabled such a devastating event to occur and I'm pleased to confirm that work on phase two has already been going on for several months those who lost
03:17:22 on for several months those who lost friends and relations those who lived in the tower and lost both their homes and everything they owned and those who live close to the tower and were directly
03:17:33 close to the tower and were directly affected by the fire all want to know how it was possible for a disaster of that kind to occur but before we can answer that question we need to
03:17:44 answer that question we need to understand in some detail the course of events that took place so that in Phase two we can ask the right questions of the right people in the course of doing
03:17:56 the right people in the course of doing that we may also be able to confirm or dispel some of the rumors and suspicions which have surrounded the events of that night this inquiry is unlike any other
03:18:09 night this inquiry is unlike any other in the number of core participants and I would suggest in the scope and complexity of the evidence it has considered and will yet have to consider there are
03:18:21 will yet have to consider there are currently a total of 598 core participants of whom 568 are individuals 10 are governmental or institutional
03:18:32 10 are governmental or institutional bodies of one kind or another and 20 are commercial bodies over the last 12 months the inquiry team has collected sifted and disclosed over 20,000
03:18:45 sifted and disclosed over 20,000 documents not including the many witness statements we've also received all those documents had to be checked for relevance and to ensure that no personal
03:18:57 relevance and to ensure that no personal data was inadvertently disclosed in contravention of the data protection legislation those documents which have been referred to in the course of the
03:19:08 been referred to in the course of the hearings have been published on the inquiries website and we shall continue to publish fresh documents in that way as appropriate after first informing the core
03:19:20 after first informing the core participants of our intention to do so the inquiry has received 668 statements from firefighters most from members most
03:19:32 from firefighters most from members most were from members of the London Fire Brigade but some were from other regional Fire and Rescue Services which provided assistance on the night in question
03:19:42 question it has heard oral evidence from 88 of those witnesses including fire fighters control room officers and officers of the London Fire Brigade including the
03:19:53 the London Fire Brigade including the Commissioner herself and other senior officers statements from 262 individual Fire & Rescue personnel have been read
03:20:04 Fire & Rescue personnel have been read into the record the inquiry has received 307 witness statements from a total of 275 bereaved survivors and residents for
03:20:17 275 bereaved survivors and residents for which I am particularly grateful knowing how difficult it must have been for many of them to describe their harrowing experiences 35 bereaved survivors and
03:20:28 experiences 35 bereaved survivors and residents gave evidence often in very moving terms a total of 266 witness statements that's 47 from bereaved friends and relatives
03:20:41 47 from bereaved friends and relatives 150 from survivors and residents of the tower 68 from residents of the walkways and one from a relative of someone who survived have been read into the record
03:20:53 survived have been read into the record and form part of the evidence before the inquiry the inquiry has also received statements from representatives of the Metropolitan Police Service the London
03:21:05 Metropolitan Police Service the London Ambulance Service and others who were present on the night the inquiries also had the benefit of hearing from many expert witnesses all of whom are leading
03:21:18 expert witnesses all of whom are leading authorities in their fields they have examined the tower and the remains of some of the equipment found within it they've provided the inquiry with detailed reports containing their
03:21:30 detailed reports containing their findings and expert opinions based on them they've given evidence in person to explain their opinions and have responded to questions directed to them
03:21:44 public hearings began in May this year with the commemoration hearings held at the Millennium Hotel which brought those who died in the fire to the fore those
03:21:55 who died in the fire to the fore those hearings have ensured that they will never be lost to sight and with the many issues of a technical nature with which the inquiry inevitably has to grapple
03:22:06 the inquiry inevitably has to grapple the commemoration hearings were followed by several hearing weeks of hearings here at Hobart bars which started at the beginning of June and have continued with occasional breaks until today as a
03:22:20 with occasional breaks until today as a result the inquiry has sat to take evidence and to hear opening and closing statements for a total of nearly a hundred days I'm very grateful to all those who've given evidence to the
03:22:32 those who've given evidence to the inquiry whether in the form of written statements or in person at the hearings despite the difficulties many of them clearly experienced in doing so it's not been possible to
03:22:45 in doing so it's not been possible to call all those who provided statements to give their evidence in person but all of them can be assured that their evidence is very valuable and will be taken into account when the report is
03:22:57 taken into account when the report is drafted the next step of course for the inquiry is to examine the very significant body of evidence amassed by it and to produce a report describing in
03:23:09 it and to produce a report describing in appropriate detail what happened that report will be produced as soon as possible having regard to the volume of material that has to be digested I've
03:23:22 material that has to be digested I've always made it clear that in discharging the inquiries terms of reference it will seek to carry out as far as it properly can an investigation into the deaths
03:23:33 can an investigation into the deaths caused by the fire of a kind that will make it unnecessary for the coroner to pursue her own investigations much of the evidence required to enable the necessary findings to be made is already
03:23:46 necessary findings to be made is already available but it's possible that some may still be missing piecing together the evidence relating to each person who died is a complex task and one in which
03:23:58 died is a complex task and one in which I understand that those who represent the bereaved would like to join I welcome their offer of assistance and hope that insofar as they consider that the material available at this stage is
03:24:11 the material available at this stage is insufficient to enable me to make all the findings needed to meet the coroner's requirements they will help me to identify what further evidence they think might be obtained within the scope
03:24:23 think might be obtained within the scope of the inquiries terms of reference it may be desirable to hold further hearings for that purpose during the course of next year with a view to producing a supplemental report in the
03:24:38 producing a supplemental report in the light of the conclusions reached in fate in the phase 1 report it may be possible to make certain recommendations without waiting for the final report at the end of phase 2 I'm going to have a say
03:24:49 of phase 2 I'm going to have a say little bit of more about that and moment however some of the bereaved survivor and resident core participants have expressed the view through their counsel that in the light of the
03:25:01 counsel that in the light of the evidence which the inquiry has already heard it's clear that there are some steps which can and should be taken immediately in the interests of Public Safety without the need to wait for
03:25:13 Safety without the need to wait for further evidence or undertaking consultation of any kind and without waiting for the publication even of the Phase one report when the matter was
03:25:25 Phase one report when the matter was last raised however they did not appear to be agreement about what those steps might be so I put in place a procedure for considering proposals from those court participants who wish to put them
03:25:37 court participants who wish to put them forward the first step was to invite the five governmental and institutional core participants who bear a particular responsibility for the safety of the
03:25:48 responsibility for the safety of the public or perhaps a section of it to tell the inquiry what steps they had already taken in response to the fire or intended to take in the near-future position statements have now been
03:26:00 position statements have now been provided by all those bodies and have been published on the inquiries website the next step is for core participants and the inquiry himself to put forward
03:26:12 and the inquiry himself to put forward suggestions of their own and comment on those put forward by each other the expert witnesses instructed by the inquiry will also be asked for their views depending on the outcome of that
03:26:24 views depending on the outcome of that process it may be desirable to hear argument about the merits of some of those proposals before reaching a final decision as I've said I think it likely
03:26:35 decision as I've said I think it likely that I shall want to consider some recommendations in the light of the findings in the phase 1 report in general however I think that before doing so it would be wise to canvas the
03:26:47 doing so it would be wise to canvas the views of those who have relevant experience in order to avoid unintended consequences of an undesirable kind I shall consider how best to do that in
03:26:58 shall consider how best to do that in the
03:26:58 the to the proposals that come forward under the procedure that I've outlined let me move on for a moment to deal with phase two as I've said work on Phase two has
03:27:10 two as I've said work on Phase two has been underway for many months but I should like to start the phase two hearings as soon as possible because I know that people are eager to shine a light on the various actions and
03:27:22 light on the various actions and decisions that ultimately led to the disaster however there is still much work to do perhaps I may be forgiven for taking a moment or two to explain why
03:27:34 taking a moment or two to explain why phase two involves examining in some detail the design and execution of a substantial building project that took over four years to complete as well as a
03:27:45 over four years to complete as well as a range of related matters like all such projects it generated a huge number of documents in one sense that is good because much of the story will be told
03:27:56 because much of the story will be told by the documents themselves but it also means that there are a very large number of them to be reviewed redacted where necessary and digested in addition the
03:28:08 necessary and digested in addition the inquiry will be examining the regulatory framework and the role of the relevant authorities in relation to it as well as the response of various organs of central and local government to the
03:28:20 central and local government to the disaster again there will be a significant amount of material relating to these questions the inquiry currently expects to disclose over 200 thousand
03:28:33 expects to disclose over 200 thousand documents to the core participants it's about to start doing so but the exercise is currently not expected to be completed until the autumn of next year
03:28:46 completed until the autumn of next year the inquiry will also be obtaining witness statements from all those involved in particular from those who are most closely involved in the refurbishment project again that work
03:28:58 refurbishment project again that work has been underway for some months but there is still a lot to do and new questions that need to be put to potential witnesses are likely to emerge from the documents as they are examined as the inquiries
03:29:13 as they are examined as the inquiries lawyers become familiar with the documents they're likely to identify new questions to put to potential witnesses finally in order to enable the choir the inquiry to probe deeply into the work of
03:29:26 inquiry to probe deeply into the work of the council the TMO and the various contractors it will be necessary for its noises and the lawyers for the various core participants to become thoroughly
03:29:37 core participants to become thoroughly familiar with all the material to be sure that they have obtained everything that is relevant to our work the investigation must be thorough and the
03:29:49 investigation must be thorough and the work to which I have referred inevitably takes time given the scale of the preparations that have to be carried out I think it unlikely that it will be
03:30:00 I think it unlikely that it will be possible to start phase two hearings before the end of next year however careful and detailed preparation which enables us to focus on the aspects of
03:30:11 enables us to focus on the aspects of the project that are of real significance should make it possible to ensure that the hearings once begun can be completed within a reasonable time I
03:30:22 be completed within a reasonable time I know there's a certain amount of dissatisfaction with the rooms that the inquiry has been using for the phase 1 hearings we're well aware that many people had hoped that we could find
03:30:33 people had hoped that we could find rooms in or at least nearer to North Kensington but although we made many inquiries we were unable to find anywhere that could adequately accommodate our various needs we've done
03:30:47 accommodate our various needs we've done our best to ensure that the rooms of home and bars are as useful and friendly as possible and we're very grateful to the staff of de Vere for their assistance in helping us to do so and their willingness to
03:31:00 us to do so and their willingness to accommodate some of our more demanding requirements at the same time however we've continued to look for somewhere suitable further west we're conscious
03:31:12 suitable further west we're conscious given the scale of phase 2 that we should require larger premises in order to accommodate the requirements both of legal representatives and of
03:31:23 both of legal representatives and of those from the local community and elsewhere you wish to attend the hearings I'm pleased to tell you that we have fans from premises in West London
03:31:34 have fans from premises in West London which have recently become available and which would provide us with what we need including a larger hearing room we've begun negotiations to enable us to
03:31:45 we've begun negotiations to enable us to take these premises and if all goes well we should be able to move there in time for the start of the phase two hearings
03:31:54 finally I'd like to express my thanks to all those who've been involved in these hearings for enabling them to be conducted in a collaborative way thereby helping to ensure that we've been able
03:32:06 helping to ensure that we've been able to obtain the fullest possible picture of what happened during the course of the night when the fire raged through Grenville town they include many witnesses who've given evidence in
03:32:18 witnesses who've given evidence in person difficult though that may have been at times counsel and solicitors representing the core participants the members of the inquiry team the press
03:32:29 members of the inquiry team the press you've been reporting our work on a daily basis and of course all those who supported the hearings whether as transcribers document managers pushers councillors members of the technical
03:32:42 councillors members of the technical support team or members of the staff at homeand bars it would not have been possible to conduct these hearings without your efforts and I'm very grateful to you all and finally can I
03:32:54 grateful to you all and finally can I just wish you all a good break over Christmas or whatever celebrations you're going to have I'm sure you all deserve it thank you very much indeed
03:33:07 well that concludes the phase 1 hearings and we shall be in touch in due course to let you know when we're going to sit again