Dr Barbara Lane continues expert evidence on fire risk assessment, focusing on Carl Stokes's assessment of the AOV smoke ventilation system at Grenfell Tower, failures to document maintenance issues, and the implications for risk calibration.
00:20:40 good morning everyone welcome to today's hearing
00:20:43 hearing today we're going to hear further evidence from dr barbara lane so without more ado i shall ask the usher to invite dr lane into the hearing room
00:21:06 good morning dr lane morning we're ready to continue yep bit nervous this morning so hopefully i'll just need to calm down you're probably not the only one but right here
00:21:17 right here good good yeah yeah no i will say that if you don't mind yeah
00:21:22 mind yeah good all right well thank you mr miller when you're ready mr chairman thank you good morning members of the panel uh good morning dr lane yep um i'd like to turn now please to the question of the aov system at grenfell and when i
00:21:33 the aov system at grenfell and when i say the aov system i mean the old one yes not the new one understood yeah right now i'd like to look with you if i may mr stoke's assessment of the aov system and you address that in chapter
00:21:45 system and you address that in chapter eight of your report sections twelve point three to twelve point five and just for the reference it's a blar p two five zeros twenty seven two pages two six six two two eight one
00:21:57 two six six two two eight one now can i just show you pay paragraph 12.3.13
00:22:02 12.3.13 yeah
00:22:03 yeah blarp250 is 27 at page 267 which is two pages into your analysis yep
00:22:12 and you say there at 12.3.13 having quoted from past 79 in the previous paragraph yeah
00:22:22 yeah on this basis it is reasonable to expect a risk assessor for a building which relies on such a system to be able to describe the system performance and the consequences should
00:22:33 performance and the consequences should that system be non-operational yeah my question is are you basing your opinion did you express that on the parts of clause 15 of past 79 that are referred to
00:22:46 that are referred to yes and and say my own experience and just i should be very clear it's at a very basic level so very basic performance requirements right
00:22:58 right and
00:22:59 and is it your opinion that the reasonably competent fire risk assessor should consider the potential for means of escape um to be compromised by a ventilation
00:23:10 to be compromised by a ventilation system that doesn't work if the means of escape relies on the vent on a ventilation system and whichever components of the means of
00:23:22 and whichever components of the means of escape
00:23:23 escape routes rely on the ventilation system yes it's relevant to the risk assessors assessment yes so just to summarize see if i've got this clear is the gist of
00:23:34 if i've got this clear is the gist of your opinion that a fire risk assessor needs to examine whether an active fire protection measure such as an aov system is actually working and is actually subject to a proper
00:23:46 and is actually subject to a proper inspection and maintenance regime and if it's not
00:23:50 it's not then to assess the adequacy of other protection measures to mitigate against the increased risk yes but in it but first for any any type of we'll say
00:24:01 first for any any type of we'll say smoke ventilation system i would not expect a risk assessor unless they had expertise in this very it's a complex area in my opinion
00:24:13 it's a complex area in my opinion to carry out a massive inspection as a matter of course what i've made clear when i looked at mr stokes work was they any risk assessor should be
00:24:24 was they any risk assessor should be able to rely on evidence from routine inspections or a simple fire strategy document that sets out enough information to form a view i don't want to imply mr stokes should
00:24:35 don't want to imply mr stokes should have done a massive inspection of that system of grandfather in any way yep no but the pr the premise of my question is if
00:24:43 if the fire risk assessor learns that the aov system isn't working or isn't working properly or has no information as to whether it's
00:24:54 or has no information as to whether it's being properly maintained and inspected regularly yes then is your opinion that that fire risk assessor needs to assess the adequacy of the other protection measures in the building yes so both
00:25:06 measures in the building yes so both those problems are relevant to the assessment of risk and you one needs to determine whether or not
00:25:15 or not alternative control measures are required and if if the fire risk assessor fails to consider both of those problems uh does that affect the suitability and
00:25:27 uh does that affect the suitability and sufficiency of the fire risk assessment it can affect the suitability and sufficiency of the fire risk assessment if the risk to life is very dependent on the performance of that system or any
00:25:40 the performance of that system or any system and no other control measure is put in place now bearing in mind what you just said about not expecting mr stakes to undertake a massive and complex examination of the aoe system bearing
00:25:51 examination of the aoe system bearing that in mind yes when a fire risk assessor assesses a building what in your view should somebody in mr stakes's position do by way of examining the aov its operation
00:26:02 way of examining the aov its operation and its
00:26:03 and its maintenance um i just am very conscious of the circumstances in grenfell tower okay we're focusing let's focus on grenfell tower yeah so
00:26:15 grenfell tower yeah so as you will know from my report i didn't make any comments about inspection i i focused on mr stokes raising his
00:26:29 i i focused on mr stokes raising his he
00:26:30 he he asked several times for evidence the routine testing and
00:26:36 and his opinion on the frequency of maintenance if it was occurring okay
00:26:43 okay and i focused on that when i was giving my opinion about his work yes and you do say it to 12.3.15 it's on the screen that you wouldn't that you would expect him to make reasonable inquiries
00:26:54 expect him to make reasonable inquiries of the kc tma of the system's function or ask for the functionality yes it would be demonstrated in your opinion did he do that did he make reasonable inquiry well he
00:27:05 did he make reasonable inquiry well he he wrote it into several risk assessments that he needed to be i mean my words reassured that that information was available again it's not so simple though because
00:27:16 again it's not so simple though because there are other pieces of evidence that show that he became aware it was substantially not functioning and then i'm just trying to remember the phrase
00:27:27 i'm just trying to remember the phrase beyond repair and those two issues were not recorded in the the risk assessment that came after he became aware of those two pieces of information
00:27:40 aware of those two pieces of information should mr stokes examine the records for of operation and maintenance in my opinion yes he he he gave the impression in his risk assessment he he
00:27:51 impression in his risk assessment he he may have tried to because he said he needed to know if they were there i don't want to translate too much else into that but he wrote down please confirm so i assume he either didn't
00:28:03 confirm so i assume he either didn't know
00:28:04 know or went to find them and couldn't he i'm not aware of the status and should the should mr stakes have noted the relevant records that were missing in his fire risk assessment the relevant records
00:28:17 risk assessment the relevant records if if records were missing to note them i think that that's the next level look i know how few records there were so it's hard to say that he should have listed out things
00:28:29 that he should have listed out things that weren't there why would you expect mr stakes to ask for the functionality to be demonstrated well in so
00:28:38 in the absence of anything else um he seemed to be under the impression i mean i don't have his risk assessment in front of me there i think he i can't remember if he thought it was weekly or
00:28:49 remember if he thought it was weekly or monthly testing was happening or he was certainly asked about that anyway i'll keep going and i think if he was concerned when he if if he
00:29:00 if he was concerned when he if if he tried to look for records and i don't know
00:29:02 know and if he was concerned about the absence of records an alternative route to him would be to witness the so-called routine test i see
00:29:14 so-called routine test i see i see so when we look at 12.3.15 you expect him to make reasonable inquiries of the functionality uh and if those inquiries don't yield a
00:29:25 uh and if those inquiries don't yield a satisfactory answer then ask for the system yeah another alternative available to you is apparently the responsible person is carrying out a weekly or a monthly test or some other
00:29:36 test or some other more detailed inspection that could be an alternative yes and would that be on each occasion that he conducts an fra so
00:29:46 so so again very much back to grenfell if the next the next time he went and we can see that's what happened it was the same situation again that shows you
00:29:57 same situation again that shows you another
00:29:59 another as we were talking about yesterday
00:30:02 yesterday and my memory was this was something that was on his yes it was he had listed this in the action plan as opposed to the main risk assessment so very much yes if that's not been
00:30:15 so very much yes if that's not been closed out as we discussed yesterday you're in a different position to the very first time you noticed it yes and the same well the same roots are open to you
00:30:27 well the same roots are open to you again but it's the responsible person now who has to deal with the matter now mr stokes told us that he would inspect parts of the aov that were visually available
00:30:37 available is that kind of inspection whatever visually available means the kind of inspection that you would expect to take place yeah i think as you're walking through depending on the system and its
00:30:49 depending on the system and its visibility i'm not because it depends how it's been designed and installed there are some features one kind of one can observe without carrying out a major inspection
00:31:01 without carrying out a major inspection what would those be for example
00:31:05 it depends what's visible mr millett so i you see i don't know if um mr stokes peered through the grills or took the girls down so i don't want to speculate but
00:31:16 speculate but there
00:31:17 there you
00:31:18 you he um
00:31:20 he um let's put it another way for example when the brigade carried out their inspection they made comments on for example the openness the openness or the
00:31:33 openness the openness or the that some of the aovs appear to be stuck in an open position and you would have to make a judgment on that based on if it looked at if it had become recently open or have been stuck open
00:31:45 recently open or have been stuck open for some time and that's a function of dirt and other conditions around the aov so manifest manifest defects on any system yeah exactly that's all that's all i would
00:31:57 all i would expect any risk assessor on unless they had experience and some risks fire risk assessors do have some substantial experience in the
00:32:08 some substantial experience in the design and installation of smoke control systems and would you expect um the ferrous assessor to document any manifest defects that they did come across during the course of that yes i
00:32:19 across during the course of that yes i think i've made it clear i think that anything you observe in a risk assessment you should record it for the records i think that's the purpose of it can we turn to page 271 then in the same part of your report and look at
00:32:31 part of your report and look at paragraph 12.3.26
00:32:36 you say there uh
00:32:39 uh at 25 which is probably the better place to start mr stokes made no reference to any deficiencies in the operation of the smoke control system mr stokes made no reference to the
00:32:50 mr stokes made no reference to the evidence that he relied on to establish his assumption nor how he surveyed the system himself to conclude the system functioned as intended that's 12.3.26 yeah where a fire risk assessor does
00:33:02 yeah where a fire risk assessor does decide to embark on an inspection of an aov system yeah would you expect them to produce
00:33:07 produce a survey report or some kind of record in the fra or the action plan if sorry if they embark on an inspection is that what you said yes
00:33:18 is that what you said yes um
00:33:18 um yes i would i don't want i think when i was writing this is to do with the fact he said yes rather than no and his record so i assume anyone who ticks yes
00:33:32 so i assume anyone who ticks yes has paperwork or other evidence that allows them to take yes okay if if he had surveyed and that that's probably quite a strong word but if he had
00:33:43 quite a strong word but if he had surveyed a limited part or certain visible aspects or he had any other observations from his time in the tower i i would expect
00:33:54 his time in the tower i i would expect him to make that clear because the scale of information allowing him to say yes is important because of what he puts on his significant action and
00:34:07 significant action and significant actions and finding document and if we turn the page to page 272 let's look together at paragraph 12.3.36 and 12.3.37
00:34:20 and 12.3.37 under
00:34:21 under 12.3.36 you said mr stokes had a responsibility to identify the risks to relevant persons due to the inoperability of the smoke control system when conducting his risk assessments as i've described he makes
00:34:34 assessments as i've described he makes no evaluation of such risk yeah how would you have expected him to evaluate the risk presented by the aov system yeah
00:34:46 yeah so so generally because this has been drawn into the new system now so i'm dealing with that in more detail in my other report but but generally generally
00:34:58 generally you you need to understand two things so if the system is relied on for escape in the lobby or just to protect the stair sorry that's two
00:35:10 protect the stair sorry that's two things already three things excuse me and the third thing is this matter of compartmentation which regardless of the system being to deal with the
00:35:21 the system being to deal with the problem in the lobby or the stair the compartmentation is the other feature
00:35:28 feature okay
00:35:29 okay so
00:35:30 so when mr stokes became aware and he he was told quite firmly the system was beyond repair at a minimum level
00:35:42 at a minimum level he needed to ex he i i would have sympathy about what the system was for during escape at grenfell tower we'll deal with that separately but in terms of
00:35:53 but in terms of compartmentation that's an issue regardless of the functional extent of the smoke control system during evacuation or firefighting okay
00:36:04 during evacuation or firefighting okay so as a minimum i would have expected him
00:36:08 him to make clear that could also have been a problem because i don't know if the dampers were how many dampers were stuck open or how many vents were stuck open and so
00:36:20 or how many vents were stuck open and so how many floors were connected together and he didn't make that clear in his risk assessment um
00:36:30 and how would you get given that how would you expect him to have
00:36:35 to have uh evaluated the risk by which i mean calibrated it so he he looks at the aov system or he's told that it's not it's beyond repair yeah
00:36:45 yeah yeah how would he how would that feed into his
00:36:48 into his calibration calibration so i think if we think back for example to the evidence that exists about the fire that happened in grenfell tower i think it was in 2010
00:36:59 think it was in 2010 yes and the smoke spread to me several floors seven or eight i'm sorry i don't you know i don't have all my stuff in front of me but yeah
00:37:10 of me but yeah it's spread to multiple floors okay um and that's relevant um with respect to the this exposure to harm you know the number of people
00:37:22 harm you know the number of people exposed to harm okay
00:37:25 okay so the more floors that are connected together in that way the the larger the number of relevant persons exposed to harm
00:37:34 harm and you know from the risk estimator probability and consequence obviously the more people exposed to harm the more significant the consequence and that should
00:37:45 that should elevate the risk level in any building
00:37:52 would it in your opinion have should it in your opinion have caused mr stokes to evaluate the overall risk which he identified as tolerable
00:38:03 which he identified as tolerable as you know it's my opinion it was not tolerable when the smoke control system let's say very particularly with respect
00:38:14 let's say very particularly with respect to compartmentation was
00:38:17 was was
00:38:18 was not no was known not to be sufficient at the time
00:38:23 the time yes okay
00:38:25 yes okay i don't want to go on too much about this issue of escape and firefighting with the old system because it's been drawn in to the basis of compliance through the new system
00:38:36 of compliance through the new system i prefer to reserve a final opinion until i'm dealing with that now is that okay yes i understand thank you yes no but just compartmentation on its own
00:38:46 own is relevant to the final risk level that was concluded for the tower at that time okay and it wasn't tolerable
00:38:59 now can we look at well i can summarize it i think in carl stakes his three fra action plans yeah for grenfell tower from 2009 to 2012.
00:39:10 from 2009 to 2012. in 2009 he was still at salvos of course as we know he consistently wrote in the in the action plan it is not known if this system is serviced and maintained and he asked the tma to confirm that the
00:39:22 and he asked the tma to confirm that the aov was serviced and maintained we can look at an example if you like but you'll recall that in on each occasion he marked the action in red to show that it was a high priority correct yes now given given that given that mr
00:39:35 yes now given given that given that mr stokes had consistently raised this issue over a three year period yeah would you have expected him to raise the absence of records and the implication may be that there's a lack of maintenance in a more explicit way with
00:39:46 maintenance in a more explicit way with janice ray rather than merely repeating the same problem in each successive action plan well you either accept that high priority is high priority and i think he classified it as high
00:39:58 and i think he classified it as high priority every time but i think on the second and particularly the third time i mean that's a trend isn't it and we've been talking about that it's a tr it's a failure of the fire risk management
00:40:10 failure of the fire risk management system to deal with the life safety system
00:40:15 system so i mean i think you're asking me should he have sat everybody down i mean you know i think he should have but i i think i'm
00:40:23 think i'm you know he did raise it as a high priority for three years he's a responsible person did nothing about it and should the fact that he he couldn't confirm
00:40:35 couldn't confirm or couldn't obtain confirmation that there were adequate arrangements in place for servicing and maintaining the aov system at grenfell over that period should that fact itself have affected
00:40:47 should that fact itself have affected the risk rating of the tower yes in my opinion
00:40:51 opinion how to what extent so it's as i said a few minutes ago if you don't know a life safety system is being maintained
00:41:04 is being maintained you would normally start by you know having a higher risk level you would say to the responsible person i need the following to bring it back down to a lower level that's the
00:41:16 down to a lower level that's the conversation i would have so so you show the consequence of not knowing
00:41:22 knowing the action is meant to help the responsible person bring it down you know let's say we'll just say going up and down one level for here then what subject to me receiving proof
00:41:34 then what subject to me receiving proof of routine inspections and maintenance please note i consider the risk level would drop back to x and given the provisions of past 79 and for our note perhaps your recollection
00:41:46 for our note perhaps your recollection clause 16.3 k do you think that it was a shortcoming in the fire safety management of grenfell tower which mr stokes should have identified and raised in his fra namely the fact
00:41:58 and raised in his fra namely the fact that after three years he could still not confirm uh adequate maintenance arrangements yeah because that's different to the first time you find it it's evidence of a consistent failure yes and so even more relevance
00:42:11 failure yes and so even more relevance to to elevating risk the risk level and did that failure uh affect the suitability and sufficiency of each of those fras and in particular the
00:42:22 each of those fras and in particular the november 2012 fra oh in particular november 22 why are you saying because it's the third time oh the third time well i um
00:42:31 well i um is
00:42:32 is particularly 2012 yes particularly 2012 and thereafter and exactly and thereafter yeah so it's it's an increasing exactly so
00:42:43 so it's it's an increasing exactly so it's further and further evidence of a protective feature being unreliable by means of the responsible person not demonstrating their risk management
00:42:55 demonstrating their risk management system
00:42:57 system is looking after it appropriately yes thank you now then we come to october 2014.
00:43:02 2014. and i'll just let's just look at this uh it's cst403157 page 26.
00:43:09 page 26. i'll just show you the first page to say that we've got yeah the date firmly in mind
00:43:14 mind cst403157 there's the first page 17th of october 2014 grenfell tower yeah fra if we go to page 26 we see section 9 where mr stokes deals with the aov just
00:43:26 where mr stokes deals with the aov just below halfway down the block of text on your screen yeah and i'll read it out he says this there's an automatic opening smoke ventilation system located on each flat stroke lift lobby area there are
00:43:37 flat stroke lift lobby area there are two sets of vents each of two vents on opposite walls on the flat lift lobby areas there is a smoke detector located on each flat stroke lift lobby area which upon activation opens the vents on that floor level
00:43:48 that floor level two vents are for inflow air the other two are extraction the mechanical extraction units and the control panels for these vents are located in the roof level plant room on the wall there's a manual override facility located in the
00:44:00 manual override facility located in the ground floor lift lobby area for use by the fire service please see section 17 above means of giving a warning in case of fire for more information of the lift stroke flap lobby area detectors as part
00:44:11 stroke flap lobby area detectors as part of the building's refurbishment this smoke extraction system is being upgraded this currently installed system was serviced by rge services on the 11th october 2013. this smoke extraction system incorporates dampers within the
00:44:23 system incorporates dampers within the ductwork i've read that at length to you um
00:44:26 um what you can see here yeah uh let me ask you
00:44:30 you it's obvious in a sense he didn't include any details uh from what he'd been told
00:44:35 been told earlier in the month that the system was beyond repair exactly so first of all it's a really good summary of the system and it shows understanding yeah and then as the evidence shows
00:44:48 and then as the evidence shows um i don't know if you're going on to show that particular evidence but mr stokes had met i think it wasn't a chub and they had been uneasy to test the
00:44:59 and they had been uneasy to test the system because it was so
00:45:04 it was so in the condition it was and then it was i think the following week that mr basman confirmed the system was beyond repair the all the dates are there 9th of october yeah for
00:45:15 dates are there 9th of october yeah for the reference it's that cst4 zeros one six two eight page two i do we can would you like no no it's okay but i just think the point is as the evidence shows there was two substantial
00:45:27 there was two substantial pieces of information that mr stokes himself was personally aware of as opposed to through another party and this is what he wrote in his risk assessment and nothing there about the
00:45:40 assessment and nothing there about the system being beyond repair nothing and my question is do you agree that with this proposition that the information he had by then received by the 17th of october that the aov system was beyond repair should have should
00:45:52 was beyond repair should have should have not only been identified expressly here
00:45:56 here but also factored into his risk calibration yes i do agree you do did the fact that the aov was being replaced or going to be replaced i mean by 2014 um in the
00:46:09 to be replaced i mean by 2014 um in the course of being replaced uh in the refurbishment of grenfell tower mean that the information that the system as it was wasn't working didn't need to be included but it wasn't being replaced in 2014 well it was going to be
00:46:22 replaced in 2014 well it was going to be replaced well going to be replaced doesn't help anybody well
00:46:26 well well so something going to be something can't offer protection so i i understand that
00:46:34 that the responsible person had made the decision to replace the smoke control system but that couldn't get done in a matter of days and weeks it was
00:46:46 in a matter of days and weeks it was going to take a particular period of time
00:46:49 time in the end it took i'm just trying to frantically remember i mean it i think it took two years in the end to reach the point where it's relevant
00:47:00 to reach the point where it's relevant to protecting life which is when it's installed and commissioned and operating it's not the intention of it protects people
00:47:11 people so until the system is working properly again
00:47:15 again the absence of that is a potential risk to life and should that have been recorded in clear and expressed terms in mr stakes's risk
00:47:26 expressed terms in mr stakes's risk assessment in my opinion it should have been and
00:47:29 been and ought to have is this right ought to have fed through to his calibration of the overall risk to life in the building yes yes like everything else yes yes now can i then take you back to your um report
00:47:41 report where we were blarp25027 and this time go to page 273 and i'd like to look with you at paragraph 12.3.39
00:47:52 paragraph 12.3.39 and you'll see it's the very top of your screen
00:47:54 screen you say this um
00:47:57 um the only time mr stokes raises the need for a mitigation measure is in his 2014 record of significant findings and action plan cst 600
00:48:06 cst 600 where he states can it please be confirmed what compensatory measures if any are being put in place whilst the installed smoke extraction systems are being upgraded
00:48:17 being upgraded and if we look a little bit lower down your page
00:48:20 your page you say it 41 mr stokes had had recorded no such significant finding for the four years previous to this when the system was also not functioning yeah
00:48:31 yeah uh as the risk assessor it was a responsibility of mr stakes to propose relevant control system actions to mitigate the hazard of a non-operational smoke-controlled system yeah uh
00:48:42 uh would what would you have expected a reasonably competent fire risk assessor who didn't have specialist knowledge of the aov system to have been able to propose about mitigation measures so i i
00:48:53 propose about mitigation measures so i i wrote that there i think it's very important to understand how i wrote that because remember the risk assessor took the decision to rank the building as tolerable he he didn't make the decision to to
00:49:05 he he didn't make the decision to to elevate the risk level wait for information and drop it back down okay
00:49:11 down okay so
00:49:12 so if the risk assessor is running with tolerable
00:49:17 tolerable it means
00:49:19 it means that's why i would be much stronger than normal about their duty to have factored in some kind of control and to made proposals for control because they were
00:49:32 proposals for control because they were so satisfied to retain the risk level are tolerable i i don't want to go through a list of issues today
00:49:43 go through a list of issues today because that's become relevant to the work i'm doing at the moment for this other report so i prefer to get into the detail of different types of mitigation
00:49:55 different types of mitigation as a function of what the system is there for in the first place right okay i think you've answered a slightly different question i have which is which is helpful in itself but and was later
00:50:08 is helpful in itself but and was later on in my little plan but never mind can i just go back to the question i was going to ask you which was you you say here at 12 30 12.3.39 yeah uh that he raises a need for a mitigation measure
00:50:20 mitigation measure um my question is on the basis of what stoke mr stakes was told in 2014 and knew about the aov system
00:50:30 system and
00:50:31 and the maintenance and operation or otherwise
00:50:35 otherwise can you identify a mitigation measure which you say he reasonably ought to have identified to the tmo so i'm saying to you that he chose to keep the risk
00:50:46 to you that he chose to keep the risk leveler tolerable and so he needed to have a list of items that allowed him to do that and what would that list include i very much by way of example very much by way of
00:50:57 way of example very much by way of example
00:50:58 example because i'm dealing with that at length at the moment for because it's being drawn in to the new system didn't want to go through a list today right but well then by keeping grenfell
00:51:10 right but well then by keeping grenfell tower tolerable this may help at this stage by keeping grenfell tower at tolerable
00:51:16 tolerable i assume that mr stokes understood how he was going to maintain compartmentation when the dampers when the aovs were not were apparently not able to do that
00:51:28 were apparently not able to do that and he understood how evacuation could occur across the lobby
00:51:34 lobby and he understood the conditions in the stair
00:51:38 stair the potential conditions in the stair without the control of smoke in the lobby okay so he had three
00:51:52 what can i call it three functions that he needed to be satisfied were controlled in my opinion to allow him to retain the risk level are tolerable
00:52:11 can i see if i can get further clarity on that yeah
00:52:17 yeah uh
00:52:18 uh can i show you mr todd's evidence on this yeah this is a day 168 yep page 33. can we just have that up please
00:52:37 uh and if you go please to line 20 line 11
00:52:41 11 yeah uh i i'd shown uh
00:52:47 shown uh well actually let's start in fact it's useful let's start at the uh at line three which i'm reading to mr todd by way of a question something in the 2014 action plan yeah
00:52:59 something in the 2014 action plan yeah against this particular action item can it please be confirmed what compensatory measures if any are being put in place while the installed smoke control extract systems are being upgraded only and then
00:53:09 and then um he goes on once the new extract system has been installed then a commissioning certificate for the system must be obtained stating that the smoke extraction system is fully functional the question at line 11 what would you have expected a reasonably competent
00:53:20 have expected a reasonably competent fire risk assessor to have advised on what mitigation measures were required rather than leaving it to the tma to decide
00:53:26 decide and mr todd's answer at line 15. i think he was working alongside the client so it was probably a reasonable question to ask the problem is i'm not sure what mitigation measures you could really implement you would want it fixed as
00:53:37 implement you would want it fixed as soon as possible but you wouldn't go to a waking watch i suggest so it's very difficult to come up with mitigation measures for a non-functioning or not adequately functioning smoke control
00:53:48 adequately functioning smoke control system yeah do you agree with mr todd's evidence there i i i recognize the difficulty um
00:53:58 um i i just sorry i am i suppose i have to say i'm kind of deliberately not answering your question because the answer to that question has become so pertinent
00:54:07 pertinent to
00:54:08 to the
00:54:10 the extra work i've been asked to do so i don't want to go through a big list today well i'm not going to push you to do that is that okay but to have a control measure
00:54:21 to have a control measure to maintain compartmentation in a high-rise residential building with a broken smoke control system um
00:54:30 um is difficult unless one can for example i'll just give one example now physically lock down if there was a way to go and physically
00:54:41 to go and physically force close the aovs and be satisfied maybe they were able to offer some
00:54:52 help limit smoke spread in the event of a fire okay but that may have been very difficult to grantful tower i'm not saying i'd er that i think mr stokes should
00:55:04 i'd er that i think mr stokes should have immediately instigated a waking watch no so i understand mr todd's view okay
00:55:11 okay and so i think it was incredibly difficult thing to mitigate and hence by making such a serious decision to to maintain the risk level are tolerable
00:55:24 to maintain the risk level are tolerable was a very big decision so i have to assume
00:55:28 assume there was some considerable thought made into the control measures that allowed the risk level not to change at all when that system couldn't work and does it come to i'm not going to ask
00:55:41 and does it come to i'm not going to ask you yeah that matters which is still under preparation yes and on this topic you will we will exactly i have to answer that question then yes that's absolutely fine to clear with you
00:55:52 that's absolutely fine to clear with you yeah um
00:55:55 yeah um but do i take from your last answer yes that given the difficulties you've identified yes todd's identified to be flattered yes yes the the reasonable risk of fire risk
00:56:06 the the reasonable risk of fire risk assessor would revisit the calibration of the risk for the building absolutely completely agree yeah yes now um
00:56:17 completely agree yeah yes now um perhaps before i leave this and again if this is a module seven issue please tell me but yeah can i show you what the action plan said cst403177
00:56:28 at page eight
00:56:32 and if we go to line 19 d you can see this is to be clear 2014 you can see that he says under the priority high the contractors rydens are going to be
00:56:43 the contractors rydens are going to be working to upgrade the installed smoke extraction system on the flat straight lift lobby areas and the refuse shoot rooms of this building can it be actions to be taken can it please be confirmed what compensatory measures are being put in place etc etc
00:56:56 measures are being put in place etc etc and i've shown you shown you that in yeah passage in the transcript of mr todd's evidence because i read it to him um my question is um um
00:57:06 um was that a reasonable approach for a fire risk assessor to take yeah so so just looking at that row you you the responsible person knows you know there's a problem and the risk assessor
00:57:17 there's a problem and the risk assessor is talking about compensatory measures but the intrinsic flaw in how mr stokes dealt with risk level is where this the next step at where is
00:57:29 is where this the next step at where is where the failure comes in okay so he has very correctly here asked he you know he's asked the right question okay and he he's put it into
00:57:40 question okay and he he's put it into his action plan which was used by the kctml
00:57:44 kctml the problem is just you know as he consistently did he he never
00:57:53 he never changed the risk level as a result of say big questions or big issues like this he raised some of the issues he raised were
00:58:04 issues he raised were very minor but some of them were had a substantial could have had a substantial impact on the risk of life and so his risk level needed to change until the responsible
00:58:16 needed to change until the responsible person satisfied him that it was acceptable to bring that risk level down okay so it's that flaw in the syst you know in the whole way
00:58:27 in the syst you know in the whole way um
00:58:28 um his risk assessments in conjunction with the kctmo didn't tackle risk properly yes i see so to summarize that i think and
00:58:37 and and to move on it's your opinion i think that although there's nothing wrong with the action taken which is a demand for a com for a confirmation of compensatory measures
00:58:49 of compensatory measures unless and until mr stokes received adequate confirmation he should have upgraded his risk calibration for the building yes you know yes thank you i agree now um can we
00:59:00 know yes thank you i agree now um can we uh
00:59:01 uh go to the fra itself to which this relates this document relates and that's at cst403157
00:59:10 at page 29 we're still in the 2014 period
00:59:16 period this is the 17th of october 2014 um
00:59:20 um template he used this is part 23 testing and maintenance and if you look uh fifth question down it says is there a monthly testing and annual servicing and maintenance of any automatic opening vents along with any associated
00:59:31 vents along with any associated equipment stroke devices with records kept yeah uh and the there's no uh well the box is ticked no yeah uh you can see that he ticks the box no
00:59:43 uh you can see that he ticks the box no but there's no commentary in the box in the observation box and there's no issue raised in the action plan no and that one can see that from a glance document
00:59:54 document did
00:59:55 did in your opinion did that affect the suitability and sufficiency of the fra yes because if you look at the screen here he he's actually raised testing and maintenance is ticked as no
01:00:07 testing and maintenance is ticked as no for the the detection and alarm the emergency lighting the vents the dry riser okay it's nearly everything that might be a bit of a just i'm just
01:00:19 might be a bit of a just i'm just paraphrasing now so nearly every protective measure in the building under testing and maintenance he has ticked no and i think that any risk assessor would
01:00:32 and i think that any risk assessor would step back and observe the scale of the number of nodes and realize that there is a fire risk management system problem
01:00:43 management system problem and that it needs to it is relevant to the resulting risk level until it's closed out satisfactorily thank you
01:00:53 thank you when it came to april 2016 yeah and mr stakes is fra then mr stokes
01:01:01 mr stokes i mean do you agree with the fact that he didn't explain whether the newly installed aov would come to it was operational or not didn't he didn't do that
01:01:12 do that um
01:01:13 um would you agree that that's something that he should have identified clearly in his fire risk assessment so the
01:01:22 the theoretically because i'm dealing with this very
01:01:26 this very you know
01:01:27 you know in detail in i think you call it module seven so so theoretically again
01:01:34 again i think i said this yesterday as a minimum because i don't expect a fire a fire risk assessor is not responsible for you know the quality of the system delivered during a refurbishment
01:01:48 delivered during a refurbishment but as a minimum and that's what regulation 38 is all about some simple information on you know the the purpose of the smoke control system in the tower etc he needed to have
01:02:01 in the tower etc he needed to have satisfy himself through what should have been available basic information at grenfell tower i have to be fair to him
01:02:13 i have to be fair to him that even if he had you know he did actually raise issues around regulation 38. that information wasn't available to him
01:02:21 him in the
01:02:22 in the format it should have been in my opinion and i think we're getting just a bit yeah and you cover that in another report yeah exactly and if need be you can come back to that module exactly i can be much clearer
01:02:33 module exactly i can be much clearer when we're when we have finally established the purpose of the device installed in grenfell tower during the primary refurbishment which i'm back looking at again
01:02:45 i'm back looking at again i can be
01:02:46 i can be give a fairer assessment of what the minimum expected from mr stokes
01:02:54 stokes thank you
01:02:55 thank you can i then turn to a completely different topic which is cladding cloud and friday we've already touched on the question of the exterior wall and
01:03:04 and uh its role uh or otherwise in the rro but can i then can i start with uh your report at chapter 10 blarp25032
01:03:15 report at chapter 10 blarp25032 page 97
01:03:18 and i'm going to show you two paragraphs on that page paragraph 9.7.414 and one five towards the bottom of the page at
01:03:28 at 9.7.14
01:03:30 9.7.14 you say this overall with respect to mr stokes the record of information in accordance with article 9 of the rrfsa by means of his fire risk assessment for grenfell tower incorrectly described the
01:03:41 grenfell tower incorrectly described the hazard the external wall posed by categorizing the cladding performance as fire rated when it was not in the 9.5.15 the fire risk assessment omitted significant components of the external
01:03:53 significant components of the external wall such as the insulation and infill panels the insulating core panels which were formed with combustible materials and so mr stokes significantly underestimated the hazard the external wall pose
01:04:05 wall pose now overall would you say that the assessment of the fire performance of the cladding at grenfell tower was was within or outside mr stokes's competence oh within or outside his competence
01:04:18 oh within or outside his competence his actual competency his actual competence well i i have to say no outside
01:04:25 outside sorry yes it was outside his competence by means of the facts you know i've set out the evidence in my report about
01:04:36 evidence in my report about what information he had available to him and how he described performance and that doesn't demonstrate competence in my opinion now in your experience is the assessment of the fire performance of
01:04:47 assessment of the fire performance of the external wall construction particularly of a high-rise residential building typically beyond the competence of a fire risk assessor okay so just
01:04:58 of a fire risk assessor okay so just we're getting into very general and very controversial territory there so i just want to say a few things first so
01:05:06 so for grenfell tower the fire risk assessor took the decision in 2014 to raise the cladding as a hazard in his risk assessment okay
01:05:17 hazard in his risk assessment okay and then in 2016 it
01:05:20 it you know was taken out of the hazard list and put into a statement of performance and i have given my opinions on on that basis
01:05:32 on on that basis that the risk assessor made that decision to incorporate it into the hazards
01:05:39 hazards he considered in his for you know in his statutory fire risk assessment i i i'm very uncomfortable to give big sweeping statement about such a controversial subject
01:05:51 controversial subject and the competency of a whole profession today
01:05:56 today well i am asking you i know you aren't i know well i just you know i just very uncomfortable well let me try you know it's it's a bit anecdotal isn't it if i tell you what i think about that
01:06:08 if i tell you what i think about that well that may be but yeah but uh you
01:06:12 you let me try it this way well can i answer your question a different way i don't think a risk assessor remember
01:06:19 remember the duty
01:06:21 the duty to
01:06:22 to not provide hazardous external walls lies with the we'll just call it the design team and the people who hand over the wall in the first place i've been very clear about that
01:06:34 i've been very clear about that in my report and i don't want to be unfair on
01:06:40 on you know
01:06:41 you know people who carry out fire risk assessments in that context because that appears to be the context we're operating in
01:06:52 be the context we're operating in let me
01:06:53 let me see if i can get this another another way
01:06:56 way and see if you can help me with this can i ask you please to be shamed mr todd's main report that cta 6011
01:07:06 6011 for page 22.
01:07:14 uh and uh can we look please together at what he says at paragraph 3.17 in the middle of your screen he says moreover in my experience the assessment of the fire performance of external wall
01:07:25 of the fire performance of external wall construction is quite specialized beyond the competence of typical fire risk assessors and fire and rescue service fire safety officers and often incapable of informed opinion purely on the basis
01:07:36 of informed opinion purely on the basis of a visual inspection intrusive inspection involving destructive exposure and sometimes testing of materials might be necessary again this opinion is widely held within the fire safety profession and is supported by
01:07:49 safety profession and is supported by the fia guidance to which i referred in the previous paragraph yeah and my question is do you agree with what mr todd has written there no i think it it it's like everything
01:08:01 think it it it's like everything there's different levels of competency different levels of understanding i mean there's a few things here again all terribly controversial subjects that are being discussed at length outside the
01:08:13 being discussed at length outside the inquiry
01:08:14 inquiry so i just want to go back to the whole point of regulation 38 was that there would be a fire strategy that confirmed
01:08:25 that confirmed accurately the
01:08:27 the performance of the materials used in the external wall and confirmed that they together could adequately resist the spread of fire over the wall
01:08:40 spread of fire over the wall okay as it set out in the building regulations so you shouldn't have to carry out an intrusive inspection as a matter of course
01:08:52 as a matter of course on on any building
01:08:56 i wonder if you can help a little bit further if we break this down yeah if you look at what mr todd says in paragraph 317 yeah first thing he says is
01:09:07 is the assessment of the fire performance of external wall construction is quite specialized would you agree with that yes i i think you know you have to have a thorough understanding of materials
01:09:18 a thorough understanding of materials and you know that i have been way laid into such matters like that for i've been i've told you that on whenever we started on tuesday but but can i just be clear i'm not the
01:09:29 but but can i just be clear i'm not the only person
01:09:34 around who who has that skill and there are fire risk assessors in this country who who have that skill maybe there are but i'm just trying to take this by stages because i think it would help us
01:09:46 stages because i think it would help us all to know where you apart from mr todd yeah
01:09:50 yeah so
01:09:52 so his view is the assessment of the fire performance and external wall construction is quite specialized and i think you said you would agree with that yeah i would yeah and then he
01:10:04 yeah i would yeah and then he expresses the view that it's beyond the competence of a typical fire risk inspector now there may be some who have more technical knowledge than others but would you agree that
01:10:15 would you agree that it's beyond the skill of a typical fire risk assessor yeah i think where i divert i don't i think what do you say divert from mr todd is i i just don't think it's appropriate to
01:10:27 appropriate to give
01:10:28 give very generalized answers in an expert environment like here about a subject that is has such
01:10:39 about a subject that is has such significant consequences right now the the the typical fire risk assessor should not have to carry out
01:10:50 should not have to carry out i quite understand why you say that that's as far as but the question i think that you're being asked to consider is where and you've met a lot of fire risk assessors yes i have um
01:11:02 yes i have um how many of them would have the specialist skill to assess the fire performance some of them wouldn't some of them wouldn't i i i some of them wouldn't
01:11:14 well many of them wouldn't
01:11:20 well if you can't say they just tell them well it's more i don't i don't what i don't want to be you know it's like judgmental as opposed to an expert opinion i think i
01:11:33 we've you have asked a lot about competence and we've discussed whether there's a requirement to have certain levels of competence or not and
01:11:44 and um
01:11:47 you know i'm probably aware it's an issue in
01:11:51 issue in the fire risk assessor profession but i just because remember i a lot of people would consider me to be a fire engineer though i don't consider myself to be one
01:12:02 though i don't consider myself to be one anymore and i think there are similar issues generally in the fire safety profession i i don't i think i think what i'm trying to say is
01:12:14 trying to say is i don't want to focus on fire risk assessors only when it comes to being asked an opinion about how external walls have been
01:12:26 about how external walls have been treated okay it's unfair to single out say one aspect of you know the whole circle of professions that are meant to
01:12:37 circle of professions that are meant to contribute to that aspect of safety i don't want to single out fire risk assessment right now the third thing mr todd says here which uh i i'd welcome your reaction to is that the assessment of
01:12:51 reaction to is that the assessment of the fire performance of an external wall is often
01:12:55 is often not possible purely on the basis of visual inspection do you agree with that yeah i think depending on so depending on the wall type so some walls actually are quite easy to you know you can very but there
01:13:08 easy to you know you can very but there are certain wall types um
01:13:11 um [Music]
01:13:14 i think i'm going to say this out loud particularly formed with acp yeah where to form a view purely based on what you see
01:13:25 see is you know it is could be incredibly unreliable yeah okay well it would it would seem to me and tell me if you think this is yeah right or wrong that if you have a
01:13:37 right or wrong that if you have a composite
01:13:38 composite panel yeah there's cladding yes you can't tell from a visual inspection what the nature of the core exactly so that will perform so
01:13:50 exactly so that will perform so absolutely but i think you would agree with what mr todd says in that respect but then i think so i think you know it's it's it's such a dangerous subject because of the consequences
01:14:01 because of the consequences um
01:14:04 um but the cladding so the panel and then as we've covered at length here what's behind it together you know so so
01:14:15 together you know so so so
01:14:16 so so for a fire risk assessor they are entitled to through regulation 38 that basic information these are the cavity
01:14:27 information these are the cavity barriers and we install them properly here is the insulation and it is what we were meant to do and this is the clouding and i've given you a truthful record
01:14:37 record of its performance and fire okay it's not any fire risk assessor's fault if there's a whole system delivering to them
01:14:48 delivering to them either incorrect or absent information and that's why i don't want to criticize fire risk assessment right well thank you very much that's helpful too yeah back back to you mr minute yes um what
01:14:59 back back to you mr minute yes um what would a suitable and sufficient fire risk assessment of the external uh cladding system at grenfell tower have involved so when mr stokes made the decision
01:15:10 decision to incorporate the cladding into his risk assessment so i haven't judged him on a theoretical situation so i
01:15:19 so i um to summarize what i said in my report as far as i'm concerned he he should have read the fire strategy to understand what the materials were
01:15:30 understand what the materials were um
01:15:31 um and before he declared it fire rated which is a speci a specific performance description he needed to have
01:15:43 he needed to have information about the basic products used in the external wall to allow him to make that statement he made that statement
01:15:54 made that statement many of us before grantful would not have made that statement now
01:16:03 what would you have expected mr stokes to have known about
01:16:09 about rs 5000
01:16:11 rs 5000 rainer bond pe 55 and the lama firm cavity barriers
01:16:20 those are the basic products yeah well
01:16:25 well but i mean
01:16:28 how do i answer that question now because we know
01:16:34 so so if you so i have to bring myself do you mean bring myself back to 2016 in the apparently innocent days of looking at materials
01:16:45 looking at materials and
01:16:46 and um he he before he wrote the phrase fire rated
01:16:54 rated he needed to have a document that told him the performance of the external surface
01:17:00 surface the performance of the insulation and
01:17:04 and um because a decision had been taken to use those infill panels as well he needed to know their fire performance also so to really
01:17:15 also so to really i'm going to say really basic there's this product and i have honestly confirmed to you it has this fire performance just very basic
01:17:27 basic so the use of the performance definitions for example an approved document b at just a very basic level okay and that is your opinion building
01:17:38 okay and that is your opinion building on that answer that you would have expected mr stokes as the putatively reasonably competent virus assessor to have to have obtained the basic product information
01:17:50 information perhaps some basic plans and at least uh satisfied himself from that that he could say that they were quotes fire rated based on the information contained in those documents and approved document b when mr stokes as a fire risk assessor
01:18:03 b when mr stokes as a fire risk assessor who decided to categorize the clouding at grenfell tower as fire rated he he needed to know um
01:18:13 um i don't i
01:18:15 i don't i i i i'm not familiar with mr stokes ability to read plans or anything so i wasn't going to get into that level of detail
01:18:23 detail but that he he knew the fire the the formal fire performance of the core components of the wall when he took the decision to write fire
01:18:35 when he took the decision to write fire rated
01:18:37 rated and so sorry to drop but what do you understand by the use of the expression fire rate yeah and that that that's the whole problem so in in
01:18:48 in in a fire rated wall is a wall with fire resisting properties so it's like a compartment wall they're extremely unusual and you normally have a fire rated wall
01:19:02 and you normally have a fire rated wall in a part of an external wall because it's too close to a neighboring building but i mean the reason i asked the question
01:19:10 question is because it seemed to me to beg the further question rated to what level or i mean does it have um an established meaning yeah and if so
01:19:22 an established meaning yeah and if so what is it yeah so you know in the last while i've heard you all talk a lot about this thing about you know people are escaping past an external wall and there's rules
01:19:33 there's rules for fire resistance in that area when you're forced to walk past wall and when two buildings are very close together there's rules about fire resistance that's totally different
01:19:44 resistance that's totally different to the whole issue of grenfell tower about reaction to fire okay so fire resistance is that classic furnace test it's a different type of heating regime
01:19:55 heating regime and typically fire ratings come in timed periods
01:20:00 periods 30 60 90
01:20:03 30 60 90 120 minutes okay that's that's what fire rated means but in that case does it make any sense just to describe
01:20:14 sense just to describe a wall in this case as fire rated without attaching any time to it it it doesn't it doesn't it it's
01:20:26 it it's a terrible it's an inaccurate representation of the performance of the wall and just
01:20:38 wall and just we
01:20:39 we because i don't want to translate this out to a lot of other buildings so at grenfell tower the risk assessor raised the cladding as a hazard in his risk assessment
01:20:51 a hazard in his risk assessment and then he removed that as a hazard from his action plan and made it a statement of performance very
01:21:01 very very very specific activity and if mr stokes did not have or did not feel he had the expertise and experience to
01:21:13 the expertise and experience to read the basic product data for the basic elements of the the cladding system at grenfell tower yeah so as to be able to express an opinion
01:21:23 opinion about its fire performance using a neutral word yeah what would you have expected mr stokes to have done to not have changed from raising it as a hazard
01:21:35 have changed from raising it as a hazard into a performance statement he should never have done that in my opinion but obviously yeah anyway in my opinion and does that mean that he should simply have left it as a hazard and and left it
01:21:47 have left it as a hazard and and left it to the tmo to seek specialist independent advice that was one option available to them yes
01:21:56 and what other options would it be available to him if he didn't feel he had the experience and expertise oh sorry sorry because i'm just thinking i was thinking probably a little too much because
01:22:07 because even if mr stokes and miss ray had decided to get the information to allow any person make that statement about fire rating remember i've told you
01:22:20 about fire rating remember i've told you that even if they had opened up the building manual and i found out evidence that they did the information in there was in itself problematic
01:22:32 problematic i've dealt with that at length already so so you were not in a position anyway
01:22:39 anyway to form an accurate view on the fire performance of the external wall so so we're in multiple layers
01:22:50 wall so so we're in multiple layers of
01:22:53 inadequate descriptions of the fire performance and so missing as a result terribly the hazards the wall
01:23:04 hazards the wall posed now
01:23:07 posed now um
01:23:08 um if we look at the april let's look at the 2016 fras if we can can we go please to the april 2016 fra and let's look at the words he actually used i'm conscious that we've been having this discussion
01:23:20 that we've been having this discussion yeah the document in front of us it would be helpful i think to see it cst403161
01:23:27 page four first paragraph this is april 2016 fra but it's also in the june version as well he says here uh under description
01:23:39 well he says here uh under description of
01:23:40 of the building
01:23:44 sorry it's above just above the words description of the building top of the screen
01:23:49 screen new external cladding has been fitted to this building as part of the project of refurbishment straight construction being undertaken on and within this building the original external face of this building has been over clad the new
01:24:01 this building has been over clad the new fire rated cladding is fixed to the out face of the building by metal fixings and the whole process has been overseen by the rbkc building control department and officers they have approved and accepted the fixing system and cladding
01:24:13 accepted the fixing system and cladding used yeah
01:24:15 used yeah now
01:24:16 now mr stakes accepted in ever in his evidence when he gave it to us that at the time he wrote that statement he hadn't seen any building control documentation or or any other independent information
01:24:28 or any other independent information yeah and then it was based on an informal conversation with a representative from ryden dave hughes as it turns out yeah and also a conversation that he's had with the tmo yeah which is for our reference that's day one three nine page seventy two
01:24:41 day one three nine page seventy two twenty nine twenty five uh to seventy five line twenty five and day one three nine a page seventy one uh
01:24:50 uh uh line eight and seventy three line nine i'm just reading that into the transcript so we can find it later that's his evidence my question to you is would would you expect a reasonably
01:25:01 is would would you expect a reasonably competent fire risk assessor to make those unqualified and unequivocal statements in his fire risk assessment about cladding without having seen and analyzed for himself any underlying
01:25:14 and analyzed for himself any underlying objective basis for them no and i don't think anything should be written in the statutory risk assessment that is not accurate or proven to be accurate
01:25:26 not accurate or proven to be accurate now in your report at chapter 11 paragraph 28.1.3 at
01:25:31 at blarp250 is 40 page 86 and there's no need to go to it you described his doing so as professionally reckless behavior yes yes i did say that i just want to understand what you mean by
01:25:42 understand what you mean by professionally reckless do you mean that he didn't care one way or the other whether the cladding was or wasn't as he called it fire rated or simply that he failed to take reasonable care to check
01:25:53 failed to take reasonable care to check that it wasn't i i don't it's none of my business about caring that's not relevant to my work it was reckless because as i've been saying to you all along
01:26:04 saying to you all along um and and we know that the issue of external wall even being in a risk assessment is you call it a matter of controversy i think
01:26:14 think so when mr stokes himself took the decision to raise it as a hazard
01:26:21 a hazard and took the decision to remove it as a hazard and made it a statement of performance without
01:26:28 without any information or attempting to read information to put himself in that position i think that was reckless that action from hazard up to statement of
01:26:39 action from hazard up to statement of performance with no information would you expect a competent fire risk assessor to assume on the basis of building control oversight and approval alone that a
01:26:50 oversight and approval alone that a cladding system complied with the building regulations no and and would perform its requirements in terms of fire protection and not as a hazard no
01:27:01 as a hazard no would a statement to that effect in an fra
01:27:05 in an fra constitute the actual carrying out of a suitable and sufficient fire risk assessment a statement to the effect that building control have overseen the works yes
01:27:13 works yes uh mr stokes doesn't know what building control did when they were overseeing the works yes can you explain why a competent rip fire risk assessor should not proceed on the assumption
01:27:24 should not proceed on the assumption that just because building control have signed it off it was compliant oh signed it off
01:27:29 it off um
01:27:33 like i mean i'm sympathetic in the sense it should be compliant if it's been signed off okay so we're back to all these theoretical hypotheticals that we're going through at length of
01:27:44 that we're going through at length of this inquiry we know that there are problems
01:27:48 problems so i i understand there was a time when and i people real people cite that even now while building control said it was okay it that's very common use
01:27:59 okay it that's very common use but in terms of the statutory risk assessment okay um
01:28:05 um you know
01:28:06 you know i don't think it's sufficient to make a remark i'm not aware that mr stokes was privy to the workings of villain control on this project at all and it would be more
01:28:19 and it would be more it would be more suitable um
01:28:22 um when he took the decision to say what he did
01:28:25 did that he had independent found some other piece of information that allowed him to be sure what i'm really trying to get is whether he's simply proceeding on an assumption
01:28:37 he's simply proceeding on an assumption that building control no it's not he can't do you can't do that and if when you say you can't do that is not does the effect of not doing that mean that his fire risk assessment of the cladding was not suitable and
01:28:48 of the cladding was not suitable and sufficient his fire risk assessment of the clouding not being suitable and sufficient isn't to do with building control it's to do with him
01:29:01 to do with him calling it giving it a fire performance he had no evidence it had is that okay yes that makes sense can i just see if i can reformulate it and see if you agree
01:29:12 if you agree that it that mr stokes in saying that it was a the cladding was fire rated without any uh objective underlying evidence analyzed by him with which to make that statement meant that his his assessment as such was not suitable and
01:29:24 assessment as such was not suitable and sufficient i agree thank you
01:29:29 and as such did he fall below the standards expected of a reasonably competent fire risk assessor he fell below the standards of a risk assessor who decided to incorporate the clouding into their risk assessment
01:29:44 now let's move forward in the story we get to april 2017 and i think you're familiar with the letter from assistant commissioner dan daly
01:29:54 daly to the
01:29:55 to the various london councils we've seen the version of the 6th of april to laura johnson already that came to mr stokes on the 19th of april 2017. and uh
01:30:07 and uh he was asked by janice ray to confirm that the tmo did not have any external cladding uh on blocks of the nature described in the letter yeah we let's go to the email
01:30:18 we let's go to the email we looked at i think a little earlier it's cst403112
01:30:24 can we please go to page one and look at the foot of that page uh mr
01:30:33 stokes is sent an email from janice ray on the 24th this is at the end of the email chain after the initial sending of the letter on the 19th of april to him and and at the bottom of page one you
01:30:44 and and at the bottom of page one you can see that janice ray writes to mr stokes on the 24th of april and says carl my understanding is we do not have any blocks with external cladding of this nature are you able to confirm please i need to write back to the
01:30:56 please i need to write back to the director of housing and i think you're probably best placed to advise me on the construction of our blocks and the same day mr stakes comes back to her three hours will say later and says
01:31:07 three hours will say later and says as far as i know that is correct grenfell was clad but the cladding complied with the requirements of the building regulations lots of questions asked of writings and answers received back from them
01:31:18 back from them and
01:31:19 and that's where the exchange essentially ends
01:31:23 ends given
01:31:24 given mr stakes's qualifications and education and experience was the statement that cladding complied with the requirements of the building regulations one which he was actually qualified to make no it
01:31:36 was actually qualified to make no it wasn't and in doing so did he depart from the normally accepted standards in the fire risk assessment trade do you think he departed from the acceptable standards of a person providing safety advice would be good to have a break
01:31:48 advice would be good to have a break soon now yeah
01:31:51 would that be a good moment it would be nice if i'd appreciate that yeah yes it would we'll stop there and come back and help us 11 please thank you thank you very much
01:32:06 all right i'll possibly thank you very much
01:51:42 yes would you ask dr lynn to come back in please okay
01:51:55 all right dr lane happy to carry on yep good if if you get to a stage where you think you need another brick you indicator yeah i will do thank you very much
01:52:03 much yes yes mr chairman um i'd like now to turn to the topic with your fire risk management yes it's something we've touched on quite a lot in in the last over the last two days yes can we start with the salvas fire safety management
01:52:15 with the salvas fire safety management report of the 22nd of september 2009 and we'll find that at sal 6013
01:52:26 now take it from me that this document was sent to mr stokes on the 28th of september 2010 shortly after he won the tender for the medium risk progress buildings at the tmo we don't need to look at the email uh although just for
01:52:38 look at the email uh although just for our reference purposes as a reminder it's cst-404383 now looking at the report at page five if we can turn to that you can see that it identifies a number of statutory breaches
01:52:49 breaches there are 19 statutory breaches in all uh relating to the tmos fire safety management at that time september 2009 would you have expected mr stokes coming
01:53:01 would you have expected mr stokes coming in a year later to have satisfied himself that those deficiencies had been remedied by the time he had been formally appointed the fire risk assessor for the medium risk
01:53:12 fire risk assessor for the medium risk buildings yes i would yeah you would yes and
01:53:18 and would you have expected him at least to have investigated with the tmo what steps they were taking to carry those recommendations into effect yes because it was quite a formative
01:53:29 yes because it was quite a formative document um with all sorts of different actions and he needed to know they were closed out when establishing his own risk levels in each one of the properties yes reliant
01:53:40 each one of the properties yes reliant on that management system thank you now mr todd said that he would not have expected mr stokes to use this report as a checklist but to as he put it start with a clean sheet of paper and determine for himself whether the
01:53:52 determine for himself whether the management standards were adequate day 168 page 70 lines two to nine do you agree with that why did mr todd think it could be ignored well uh do you agree with his statement
01:54:03 well uh do you agree with his statement no i don't at all but i don't understand why he thought it could be ignored i don't agree it can be ignored you don't agree that it could be ignored now looking at page 13 in this please can we go
01:54:12 go to the first of the deficiencies identified by salvas that was the absence of a tmo fire safety policy statement as you can see there and you can see in the first row the uh recommendation by salvas
01:54:24 recommendation by salvas uh as follows it is strongly recommended that an overall tmo fire safety policy statement is developed setting out the organization's strategic fire safety objectives
01:54:36 objectives the statement includes a clear reference to achieving full compliance with the requirements of the regulatory reform fire safety order 2005 wherever it applies to premises managed and or occupied by the tmo yeah that the
01:54:49 and or occupied by the tmo yeah that the statement is signed by and formerly endorsed by the chief executive on behalf of the tmo that's the first recommendation and if you look uh at the
01:55:00 the second recommendation uh
01:55:02 uh in the
01:55:05 in the uh
01:55:08 um if you look at the second row yeah um it also uh well the second second recommendation strongly advised that adequate policy and supporting arrangements were introduced to explain
01:55:19 arrangements were introduced to explain how the tma will meet the objectives set out in the strategic policy statement service to ensure suitable and sufficient fire safety is maintained at all times throughout the managed estate yeah would you expected mr stakes to
01:55:30 yeah would you expected mr stakes to have sought and reviewed a copy of the tma's fire safety strategy or policy to to the extent that there was one at that time of course before carrying out fire risk assessments for the tma
01:55:41 fire risk assessments for the tma exactly if it had existed which it didn't
01:55:43 didn't he he should have reviewed it or asked for it and then reviewed it and can you give us very briefly a reason why that document would have been extremely helpful to him in carrying out his functions because the the the risk
01:55:56 his functions because the the the risk level
01:55:58 level produced in a building as such is a function of the fire risk management system
01:56:03 system so you have to understand the intentions of the fire risk management system and how it's being set up and so which parts of it you can rely on when you're carrying out your risk
01:56:15 on when you're carrying out your risk assessment in a building yeah
01:56:18 yeah no sorry no no can we go to cst401822 please this is a letter from mr stakes
01:56:25 mr stakes that we've seen a number of times before to janice ray on the 23rd of june 2010 yeah
01:56:32 yeah and it followed a meeting they'd had on the day before the 22nd of june 2010 yeah relating to employee fire safety training peeps yeah and the lift maintenance policy and tmo building yes and if you look at the
01:56:44 tmo building yes and if you look at the second paragraph he said this when completing any fire risk assessments for building up buildings under the control of the tenants management organization tmo of the royal borough of kensington and chelsea in
01:56:55 borough of kensington and chelsea in future and where tmm employees are present in the buildings the information in this letter will be used as the basis of the fire training and fire warden section of the document
01:57:06 you can see that's what he said there and if we go to another letter before i come to a question cst403061 this is his letter of the 27th of september 2010. yeah so janice ray yep
01:57:20 september 2010. yeah so janice ray yep following their meeting on the 24th of september 2010 he says after the meeting in the second line i would like to put in writing the management procedures and topics we
01:57:31 management procedures and topics we discussed and issues etc we discussed so that when completing any fire risk assessments for residential buildings under the control of the tenants management organization tma of the royal borough of kensington and chelsea in
01:57:42 borough of kensington and chelsea in future these standards and observations will apply the letter then went on to cover a number of matters and you can see them listed under uh employee fire training and thereafter you can see them they're
01:57:54 thereafter you can see them they're they're not going to read the list out to you
01:57:57 to you now i want to come to what you say about that in your report yeah can we look please at blarp25040
01:58:06 page 47 and this is within chapter 11 of your reporter paragraph 18.1.8 under the general heading yes mr stakes's approach to the arrangements made by the kctmo for
01:58:19 arrangements made by the kctmo for maintenance and that subparagraph eight about three quarters of the way down the page halfway now down your screen it says this the short letter produced by mr stokes is in my opinion not a
01:58:30 mr stokes is in my opinion not a thorough assessment of kctm's fire risk management system especially in light of the fact that the kctma's portfolio of buildings comprised of just under 7 000 homes more than 2 500 leasehold
01:58:42 homes more than 2 500 leasehold properties you cite from the kctmo asset management strategy 2014 to 19 dated may 2015 and there's the reference there
01:58:53 there's the reference there why do you consider that this letter was not a thorough assessment of the tma's fire risk management system well i hope the letter speaks for itself but say taking one particular item to be
01:59:06 but say taking one particular item to be clearer
01:59:07 clearer um
01:59:08 um you know uh you you showed us there that salva said to have of you know the form of fire safety strategy document even that's before you even get to policy and procedures
01:59:20 procedures and i mean that didn't exist when mr stokes wrote that letter if i've got my dates correct it didn't yeah it just simply so i i don't know how in the absence of documents that are are
01:59:34 in the absence of documents that are are needed as part of a fire risk management strategy and already advised as being missing and significant and a statutory breach
01:59:43 breach writing
01:59:44 writing a simple letter somewhere well anyway it won't go on but that letter doesn't reflect
01:59:51 reflect the kind of reviewing work needed would you have expected mr stokes yeah to carry out an assessment of the tmo's overall
01:59:59 overall fire risk management system at the outset of his contract to undertake fire risk assessments in the tma's medium-risk properties yeah i i have to say i would so if if you're
02:00:10 have to say i would so if if you're going to take on a job of that scale it wasn't one building taking on a job of that scale obviously i think the documentation should have been there so it wasn't a deeply complex task okay but but yes to
02:00:24 deeply complex task okay but but yes to take on fire risk assessments at that scale i i would expect a review of the fire risk management system and why was that very briefly
02:00:35 and why was that very briefly because everything i think because in terms of so the fire in terms of say there there's all sorts of reasons and
02:00:46 there there's all sorts of reasons and i've been through them at length in the report but just being giving some specifics here so before you start even knowing what protective measures are being relied upon in each building so
02:00:57 being relied upon in each building so the record you know the the general fire precautions what exists in the building then what are the plans in place to maintain them
02:01:09 plans in place to maintain them at an adequate performance level the you know who who in the organization is responsible for what just that level of clarity
02:01:18 clarity about how
02:01:20 about how everything that enables one to rely on general fire precautions how it will be dealt with day by day and all of that impacts
02:01:30 impacts the risk level of any building thank you okay
02:01:34 okay now going to uh blarp25027
02:01:41 which is chapter 8 of your report can we please look at that at page 209.
02:01:50 and you say it paragraph 9.10.15 yep
02:02:00 page 209
02:02:03 yes it's on the screen now um you you say i have also seen no evidence
02:02:09 evidence from any other year that mr stokes specifically asked miss ray to provide him with any updated information regarding the fire risk management system yeah and you go on to say in the next two paragraphs therefore i've also
02:02:21 next two paragraphs therefore i've also seen no evidence that mr stokes adequately assessed kctmo's overall fire risk management system either as a separate piece of work or as part of his individual fire risk assessment reports for grenfell tower instead based on the
02:02:33 for grenfell tower instead based on the evidence provided to me mr stakes appears to have assumed that the initial information he agreed with ms ray in september 2010 was the basis of management of fire risk in kctmo properties at all subsequent times
02:02:47 properties at all subsequent times now
02:02:48 now can we take it from those three paragraphs there that you would have expected mr stokes to have obtained and assessed up to date current information about the general
02:02:59 current information about the general fire safety management matters set out in the september 2010 letter when carrying out any fire risk assessment for a particular building yeah so for example when when the fire strategy did come
02:03:11 when when the fire strategy did come into you know formal existence in that was 2013.
02:03:18 for a risk assessor responsible for so many properties um
02:03:24 um i think a review of that document to make sure it was
02:03:30 it had sufficiently described the arrangements being made because you know the arrangements are an article in the order it had sufficiently described things for you or if there
02:03:42 described things for you or if there were
02:03:43 were performances or other issues you weren't clear on having read that document and a good illustration of that as you showed me earlier the table with all the different systems ticked no
02:03:55 different systems ticked no when it came to testing and maintenance so
02:03:58 so that's connected back to the understanding of the fire risk management system and the organizational arrangements planned and then implemented to make
02:04:09 planned and then implemented to make sure those boxes are not known that's why it's interconnected and the review is so important in not
02:04:19 in not obtaining and assessing up-to-date information about the general fire safety management matters yes as set out in the september 2010 letter when he came into the contract at that time
02:04:31 did mr stokes fall short of acceptable standards
02:04:36 standards yes and yes he did yes yeah and when he took on the entirety of the tmo portfolio the following year yes october 2011
02:04:47 2011 at that stage should he also again have obtained an obsessed up-to-date information about the yes sorry i meant i thought you were actually talking about that year so when he took on the entirety of the portfolio
02:04:59 he took on the entirety of the portfolio right it was particularly relevant right particularly yes but relevant even in 2010 it's relevant generally but the greater the scale of the property the more intimate you need to be the
02:05:10 more intimate you need to be the portfolio the more intimate you need to be with the workings of the virus management system yes is that okay so it's an increasing responsibility if you want to put it that way would you also have expected mr
02:05:21 that way would you also have expected mr stoke to mr stokes to have obtained and assessed premises specific information about general fire safety management matters
02:05:30 matters in 2010
02:05:32 in 2010 when carrying out 2010. can i just clarify are you asking me about 2010 because it's the first fire risk assessment he carried out is that the difference you're trying to
02:05:44 the difference you're trying to would it winkle out of me no what i'm trying to
02:05:47 trying to is that it is in 2010 when he is given the program oh yes but by the tmo after the tender exercise based on the consultant's brief of july 2010. yeah no i understand that but why or yes okay
02:05:59 i understand that but why or yes okay and it is in september 2010 that he addresses fire safety management issues in the letter we've seen yes before that as we know he did a fire risk assessment at the end of september 2009 when still
02:06:11 at the end of september 2009 when still employed or retained by salvos who who and in that entity they carried out a very terrible review of the fact that excluding i'm excluding the 2009 fire risk assessment for the foot for the
02:06:22 risk assessment for the foot for the purposes of this question so go from 2010 okay so in 2010 when mr stokes was awarded was asked to carry out fire risk assessments on multiple
02:06:34 out fire risk assessments on multiple properties is that what you're asking me correct
02:06:37 correct yes he did need to review the fire risk management system yes but for building but my question is yeah should he have done so on a premises-specific basis building by building when carrying out a
02:06:48 building by building when carrying out a fire risk assessment for a particular building in other words should he have when confronted with a building for which he was doing a foreign assessment asked himself or asked the tmo what are the fire risk management systems for
02:06:59 the fire risk management systems for this building oh i see what you mean well i mean that's what you're doing in a way but um
02:07:07 sorry i just i have to be clear so i don't give the wrong answer are you talking about the specific individuals responsible or are you asking me about how the risk management system is being implemented in that building the latter
02:07:18 implemented in that building the latter the latter so by carrying out the risk assessment and assessing the quality of what you find in the building in a way that's what you
02:07:29 in the building in a way that's what you are doing and do you criticize mr stokes for not doing that
02:07:35 but he he so i think we're talking across purposes so
02:07:39 so he he did look at systems and how they were
02:07:43 were being implemented i i'm not sure the word speaking about the same thing right well yeah let's let's leave it yeah we've already covered grenfell tower specifically and yeah i think we've already got your opinions about
02:07:54 already got your opinions about particularly in relation to box ticking and no on that yeah can we look at annex e of past 79 and look at this from a slightly different angle this is cta 703 page 106.
02:08:06 page 106. uh this is the model pro forma and i take into account what you've told us about
02:08:12 about um
02:08:13 um pro formas yeah um it's the model pro forma or for review of an existing fire risk assessment yeah so you can see it's informative and if you look at
02:08:26 it's informative and if you look at um page 111 please a little bit further on in the document you can see that there's a section within it on fire on management of fire safety
02:08:34 safety yeah that's the heading and paragraph 13.1 has a uh a heading and a box and the heading says significant changes in management of fire safety since the time of the fire risk assessment
02:08:46 time of the fire risk assessment now just pausing there yeah do you agree that that suggests that up-to-date information on fire safety management matters should be obtained by the fire risk assessor when carrying out
02:08:59 the fire risk assessor when carrying out a fire risk assessment review yeah so actually i i understand what you've been trying to
02:09:05 trying to ask me about now so if you look at this box
02:09:08 box okay and apply it to the grenfell tower risk assessment we looked at earlier the the
02:09:14 the the over a period of years the significant changes in the management of fire safety since the last time i carried out fire risk assessment is i asked them to sort out routine
02:09:25 i asked them to sort out routine inspections in the building there has been no change despite me raising it as as an action that's the type of information you'd write there about the management
02:09:36 write there about the management right that makes sense so the evidence of the management you find in the building and the cut this how it relates back to the procedures and the organizational arrangements you'd
02:09:48 organizational arrangements you'd explain here so i can't find evidence there's routine inspections when i look at certain things they're not working though i'm being reassured they're being checked yes there's to check that's how
02:09:59 checked yes there's to check that's how you would deal with management right yeah i think that may answer the question under the next box yeah um because 13 1 is significant changes exactly
02:10:10 exactly you might not find a change you might find that it's the same old same old exactly yeah there hasn't been a significant change though i asked for one to to be yeah right but i would suggest to you that that would
02:10:21 i would suggest to you that that would be more adequately answered under 14.1 it doesn't matter because the point is the same but our arrangements for management of fire safety adequate presumably you would say no because the last time i asked for something it wasn't done yeah so the significant
02:10:33 wasn't done yeah so the significant change is i asked for the following to take place it still it still hasn't occurred
02:10:39 occurred and the consequences are um if we refer back to that box with all the systems with no
02:10:45 with no i'm afraid i now have to conclude that the arrangements for management of fire safety in the tower in that year is no on the basis of the following and you'd refer back to
02:10:56 refer back to items found in the fire risk assessment now just looking at 14.1 can you tell us what assessment is envisaged would be carried out by a fire risk assessor in response to this question
02:11:09 in terms of 14.1 yes it's it's as i've described what you've witnessed in terms of the quality of what you're seeing in the building
02:11:20 of what you're seeing in the building because the quality of that is is what the fire risk management system is meant to provide
02:11:29 now mr stakes didn't include these sections in any of his fire risk assessments for grenfell tower after his first assessment that he did for salvas in 2009 yeah my question to you is would you have expected him to have included
02:11:42 you have expected him to have included them in his uh fire risk assessments he did once he'd been retained by the tma yes i would because it's a really clear way of bringing that other
02:11:53 way of bringing that other element of risk control clearly to the attention of the responsible person and can you just explain the importance of considering these sections 13.1 and 13.2 in a fire
02:12:05 these sections 13.1 and 13.2 in a fire risk assessment review
02:12:11 in the do you mean are you saying review in the context of not carrying out a full fire risk assessment that's what i think what nxt is okay so i just wanted to be clear well anyway um
02:12:23 i just wanted to be clear well anyway um the if i was before review the
02:12:28 the the best way of understanding the condition of the management as i've been saying
02:12:33 saying is particularly looking at how the significant actions and findings are being dealt with in the last full risk assessment i've been trying to explain their manifestation of the success of
02:12:46 their manifestation of the success of your fire risk management system can i just then
02:12:50 just then perhaps break that yeah down a little bit what we've been looking at is the fras done by mr stokes and yes 10 2012 2014 and twice in 2016. yeah
02:13:02 and twice in 2016. yeah those were new fras i would move aside the june 2016 one for the moment those were new fras not reviews of existing fras yeah nonetheless would you
02:13:14 existing fras yeah nonetheless would you expect mr stokes to have uh
02:13:18 uh attempted to answer the questions posed at 13.1 and 13. and 14.1 here
02:13:27 yes i understand this is in a pro forma for review yes okay leaving aside the pro forma the the concept of being clear on on the
02:13:39 the the concept of being clear on on the quality of your observations of the management system in each building is relevant to a full under and a rev and review activity and
02:13:50 under and a rev and review activity and if the responsible person conducted its own review in-house
02:13:56 in-house yeah would you have expected the responsible person to have asked itself these questions and answered them fully candidly yeah i'm not aware that that happened though no indeed would you
02:14:08 that happened though no indeed would you have expected you mean theoretically would i expect a manager to assess themselves in their management of fire safety uh well
02:14:18 uh well that is the premise of the question yeah if a responsible person conducts its own review of the fra done for it by a fire risk assessor yeah in year one yeah so
02:14:31 risk assessor yeah in year one yeah so well yeah two rather after year one obviously
02:14:34 obviously i would expect someone who decides to i feel like i'm kind of saying stating the obvious if you take the decision to use this pro forma yes i think you should fill it in properly leaving aside the pro forma as a matter of principle would
02:14:47 pro forma as a matter of principle would you expect a responsible person when reviewing
02:14:51 reviewing the fire risk assessment done for it by a fire risk assessor the year after it was done to have addressed the questions at 13.1 and 14.1 even though they're in
02:15:02 at 13.1 and 14.1 even though they're in a pro-forma there yeah i think i i just i i really don't think i don't really understand what what you mean okay so
02:15:14 what what you mean okay so the the fire risk management system is a set of organizational arrangements that produces something in a building okay
02:15:24 okay so
02:15:25 so i see this review pro forma here is is a review of what's been found in the building the last time the risk assessment was done that's what i see
02:15:36 assessment was done that's what i see here
02:15:37 here okay
02:15:39 okay yes i think we're i i think we're talking about two separate things i wonder if i can help i think mr millet is asking you is if the responsible person
02:15:49 person decided to conduct the review yes uh assessment for himself yes for itself would you expect it to ask these sort of questions of itself
02:16:01 questions of itself and
02:16:03 and to ensure that the system was running properly yeah i think so but
02:16:11 it in this review mode it has to be um off the basis of some findings in the last fire risk assessment which would mean
02:16:23 which would mean the documentation in whatever form has set out matters that allow you to review them and so fill in these boxes
02:16:34 fill in these boxes if if the fire risk assessment for that property has no mention of the relevance of management i don't know how you can fill in this particular form
02:16:49 yes
02:16:52 now if mr stokes did not assess significant changes in safe fire safety management in his subsequent fire risk assessments for grenfell tower um would you criticize him
02:17:04 um would you criticize him can you just say that if mr stakes did not in fact assess significant changes or the absence of required changes perhaps in his subsequent fire risk assessments
02:17:15 in his subsequent fire risk assessments for grenfell tower having raised a management question or an issue which um yeah
02:17:21 um yeah uh impinged on management yeah would you criticize him i would can can i just go back i think you're asking me if a competent person who has designed and is responsible for
02:17:33 who has designed and is responsible for a fire risk management system irrespective of what the fire risk assessor is doing if they are responsible for checking that the arrangements they've put in place
02:17:43 place are both complying with the order and delivering what's required in each building and they're doing that as part of this particular type of review the answer is yes i would expect them to do
02:17:54 answer is yes i would expect them to do that as a responsible person thank you now can we look at past 79 cta 703 page 50 and i'd like just to examine clause 16 of it with you for a moment
02:18:05 clause 16 of it with you for a moment uh if we look at sub paragraph one on the left hand side of the page under general it says in the fire risk assessment fire safety management c 3.47
02:18:16 assessment fire safety management c 3.47 needs to be regarded as of equal importance to fire protection measures in its broader sense fire safety management includes certain policies and procedures designed to prevent the occurrence of fire by eliminating or controlling fire hazards however most of
02:18:28 controlling fire hazards however most of these aspects of fire safety management have already been considered in clause 13.
02:18:33 13. and in subparagraph 2 you can see below that
02:18:36 that and i think we need to scroll down a little bit to see the entirety of it uh there is a a 13 point list a to m of matters which are to be included in
02:18:50 of matters which are to be included in fire safety management you can see the list there now
02:18:54 um and in some paragraph three if we could just scroll down to that and have that on the screen which is at the bottom of the left hand column at the top of the right hand column
02:19:05 column it says points a to k are discussed in the sections of the commentary that follow point l is discussed in clause 19 and point m is discussed in clause 20. it is important that matters in the paragraphs that follow are properly
02:19:16 paragraphs that follow are properly considered in the fire risk assessment and the fire safety management is taken into account in the subjective judgment on overall fire risk clause 18. guidance on fire safety management of
02:19:28 guidance on fire safety management of occupied buildings can be found in clause 41 of bs 999 of 2008. and that it goes on to say that past seven was in the pro process or course of development and in
02:19:39 process or course of development and in fact as we know it came out the following year 2013. now um is it right just looking at everything i've shown you on that page that a reasonably competent fire risk assessor would be expected to consider
02:19:51 expected to consider all of the fire safety management factors covered in clause 13 16 19 and 20 of past 79 clause 13 16 19 and 20. the reason i
02:20:02 clause 13 16 19 and 20. the reason i mention those numbers is because they're the numbers of clauses listed here as as as applied to the property
02:20:11 property the responsible person had in their portfolio yes yes indeed indeed and to take those matters into account in their judgment of overall fire risk as indeed remnants yes i've made that clear yes
02:20:23 remnants yes i've made that clear yes and that's clear from roman three i think and looking at some of those factors listed in subparagraph two on page 50.
02:20:30 page 50. we can just look at that if you look at f
02:20:33 f f says
02:20:35 f says arrangements for routine inspections of the premises and its fire precautions or for more formal fire audits now in relation to that factor you've covered that in your uh report uh
02:20:47 uh report uh at some length i think at um chapter eight yeah and i'll just give the reference paragraph 15 2 15 to 19 at page 345. now can i just paraphrase
02:20:58 page 345. now can i just paraphrase um is it right that you say mr stokes repeatedly raised questions in all of his action plans for grenfell tower yeah about whether caretakers or estate service assistants esa's were carrying out their routine inspections and
02:21:10 out their routine inspections and whether records were kept but stated in the body of his fire risk assessments for grenfell tower from 2010 that they were being carried out with records kept
02:21:21 and you i think say is it your opinion that the level of inconsistency doesn't enable the reader to understand the effectiveness of the tmo's arrangements and that therefore mr stakes's approach
02:21:33 and that therefore mr stakes's approach doesn't represent an adequate assessment of risk that's correct have i summarized your opinion yes you have thank you that's a bit of a long summary on that moving in then on that basis would you have expected mr stokes as
02:21:45 would you have expected mr stokes as part of the conduct of his risk assessment to have asked for and and obtained where possible records showing that routine inspections of the premises were being carried out rather than
02:21:57 were being carried out rather than simply raising it as an action and moving on
02:22:00 moving on yes
02:22:01 yes yes and particularly when he realized it could have been a repetitive problem yes and that i think partly answers my next question where a fire risk assessor has not managed to
02:22:12 fire risk assessor has not managed to obtain records of routine inspections or has simply not been given them uh and doesn't know where the routine inspections are or aren't being carried out
02:22:21 out would you expect that to have been the subject of comment in the fire risk assessment yes i would have and in those circumstances would you expect a reasonably competent virus assessor to factor that in back to the absence of
02:22:33 factor that in back to the absence of records about routine inspections into his assessment of calibration yeah that's correct as we we've discussed this morning and presumably doing is this right to increase the assessment of the risk or ball tends to increase the
02:22:46 the risk or ball tends to increase the assessment of the risk exactly so if arrangements that were being relied upon to control either preventing a fire from starting in the first place or once it has
02:22:57 in the first place or once it has ignited its spread etc it the it were back to the exposure of harm increasing and that causes your risk level to go up yes now the next question few questions
02:23:09 yes now the next question few questions i've got for you are really on the same sort of yeah line and so take them quite quickly if you look on the same page at k
02:23:16 k you could see that that is documentation of fire safety arrangements and keeping appropriate records you see that yep and if we go to page 96 in this document past 79 this is annex b
02:23:28 past 79 this is annex b and then and this is the pro forma template for a fire risk assessment we can see that there's a section where one has to consider yeah records 28. uh appropriate records of
02:23:40 uh appropriate records of and the fifth item down maintenance and testing of other fire protection systems you can see that now in your report in chapter eight and i'll just give the reference to people it's blrp 250 27
02:23:52 reference to people it's blrp 250 27 page 90 paragraph 9.3.15 you observe that mr stokes omitted the section
02:23:59 section this section from the pro former in past 79 relating to records yes you go on to say that that emission made an important difference that's a paragraph 9.3.16 again i don't need to take you to that can i just ask
02:24:11 need to take you to that can i just ask you to explain why you say it made an important difference yeah because again it's about um
02:24:18 um so
02:24:19 so it's about communicating to the responsible person
02:24:25 what you've relied upon but also where let's say you're troubled by something you're finding and giving them a really clear indication and so when it comes to records a really
02:24:37 and so when it comes to records a really clear indication that for example i mean this isn't a full list it's a sample list
02:24:44 list um
02:24:45 um that they have x and y system in the building
02:24:49 building you were concerned about the performance or their condition of them and you you made an effort to find the record and that doesn't seem to exist either so that's a really important
02:25:00 either so that's a really important signal to the responsible person of a deficient fire risk management system yes and would admitting uh
02:25:09 uh the
02:25:11 the um indication from except from practice
02:25:17 practice to to to omit record no no i don't consider it to be acceptable now if we go recording information is quite clearly explained in the rre yes yeah now if we go to cst403145
02:25:29 now if we go to cst403145 this is mr stokes's 20th of june 2016 fire risk assessment for grenfell tower his last one we go to page 30. that's that's the first page there but if we go to page 30 you can
02:25:40 there but if we go to page 30 you can see
02:25:41 see um that he's he has amended the pro forma sections relating to fire safety management uh to include uh
02:25:49 uh a question as to whether records were kept
02:25:53 kept because you can see the first question if you go to the top of the page procedures and arrangements are there routine in-house fire safety inspections and checks carried out with
02:26:04 inspections and checks carried out with records kept yes please tick that with a yes yes
02:26:07 yes yes uh and if you go um down the page you'll need to scroll down to section 21 in this on the screen under training um the first question again
02:26:18 um the first question again is
02:26:19 is with records kept you see that yeah and there's a tick and then if you go to section 23 on page 32 yeah
02:26:27 yeah two pages on there it is and the first the second third and fourth questions there and indeed the fifth in fact yeah all of those uh on that page apart from the first yeah i can see um ask
02:26:41 the first yeah i can see um ask are records kept yes uh and some of those know and some of them are yes yeah um
02:26:48 um would you agree yeah that mr stokes had effectively incorporated the separate section on keeping records in the past 79 pro forma into his own template adequately
02:27:00 into his own template adequately by
02:27:01 by splitting it up into the different sections yes i can say that and by tacking on with records kept yes who's heading yes i could say that yes yes i should have said that well i guess you sort of said that do
02:27:12 well i guess you sort of said that do you maintain your opinion that by removing the specific section we say made an important difference um i think i have to withdraw that on the basis of the word record being used
02:27:23 the basis of the word record being used elsewhere
02:27:24 elsewhere but i'm probably more concerned as you know with the absence of records generally generally not the pro forma itself yes thank you
02:27:36 the pro forma itself yes thank you now uh
02:27:37 now uh thank you now let's look at blarp250s40 at page 48.
02:27:45 this is chapter 11. and uh
02:27:49 and uh if i can go to paragraph 18.1.16 you'll see it in the middle of your screen there you say secondly
02:27:58 uh mr stakes states and this is a reference to his 27th of september 2010 letter that it is taken that if the item is on the list i.e emergency lighting in any town house then servicing and maintenance is being undertaken and
02:28:11 maintenance is being undertaken and records kept
02:28:15 and then in the next paragraph you say mr stakes did not intend to verify the undertaking of maintenance or the keeping of records by the kctmo therefore mr stokes did not intend to make his own assessment of kctm's
02:28:26 make his own assessment of kctm's arrangements and instead relied upon kctmo assertions only yeah now leaving aside whether that's factually correct which is a matter for the panel of course would you expect a fire risk
02:28:37 of course would you expect a fire risk assessor to check each and every maintenance record for a building or would it be enough for him to check a sample of records or otherwise accept the responsible
02:28:48 or otherwise accept the responsible person's assertions or policies that maintenance was being carried out i see it this is slightly different to this point here which is a generalized
02:29:01 this point here which is a generalized statement about his whole approach is 18.1.16
02:29:07 okay yes he he said he and he his intention from the start was to assume it was there and to not check that's what my com my
02:29:18 that's what my com my yes well let's break it up yeah it would was that alone was that approach
02:29:24 approach on its own a a
02:29:27 a a reasonably acceptable approach no um given that it wasn't uh
02:29:34 uh would you expect a fire risk assessor to check each and every maintenance record for a building or would it be enough to check a sample or to rely on the assurances given to him by the responsible person
02:29:46 him by the responsible person or is contained in policies yeah so the
02:29:50 the so so just again that's quite theoretical so the maintenance policy and procedures to satisfy the maintenance duties under the
02:30:01 satisfy the maintenance duties under the rro should be recorded in the fire risk management system and associated documents so you understand what's planned when who's doing it etc and then
02:30:13 and then i would expect you to depending on the quality of the particular system observed during your fire risk assessment and if you were making comments on
02:30:25 and if you were making comments on maintenance that you would check some records
02:30:28 records not carry out a full assessment of the maintenance regime for the kctmo which in itself was very difficult to do because of the absence of records yeah yes um
02:30:39 yes um so when let me see if i got this right when mr stokes ticks the box against the aunt against the question has something been done with records kept and says yes and says
02:30:52 with records kept and says yes and says yes yes what um investigation of the state of the records would you expect mr stakes to have undertaken i expect him to know that records are being kept yes and when when you say know that
02:31:04 yes and when when you say know that satisfy himself by an investigation and inspection of those records or take it on trust from the responsible no i don't i your
02:31:11 i your the risk assessment is meant to be you know it's not taking on trust you're you're checking things for the responsible person and would you check all of the records or a sample
02:31:22 or a sample for for example the aov or the lifts or the drivers you see i don't know what you mean by all of the records so there will be specific documents that allow a risk assessor
02:31:33 risk assessor understand of the fire performance of the system is being maintained maintenance goes well beyond delivering fire performance yes
02:31:43 yes so if you're asking me if if i i think you want me to give some kind of percentage i don't have a percentage but i think if you're going to take records kept for any life safety system you will
02:31:55 kept for any life safety system you will have made it your business to go and look at some records right
02:32:01 and and i take it by some you mean enough to give the fire risk assessor reasonable confidence that the measure has been adequately maintained the measure is being adequately maintained to perform
02:32:13 being adequately maintained to perform in a fire exactly okay that's helpful now can we then go back to past 79 page 50 please which is cta 703
02:32:26 yes um can we go to 16 l 16 roman 2 l which says implementation of the action plans recommendations it's one of the matters to be taken into account when
02:32:38 matters to be taken into account when analyzing fire safety management now on that if mr stokes if mr stokes was aware that the tmo had problems completing his action plan
02:32:49 problems completing his action plan recommendations on time
02:32:54 and there was a persistent and generic issue with tackling a backlog of action would you have expected him to refer in his fire risk assessments to that wider problem yes
02:33:05 yes and would you have expected him to have undertaken each subsequent fire risk assessment with that fact in mind yes and under and and factored it into
02:33:17 yes and under and and factored it into his calibration of the risk for each building yes and in view of the backlog issue would you have expected mr stakes to have offered at least general advice to those
02:33:29 at least general advice to those responsible at the tmo on the fire risk consequences that they were bearing as a result of not completing those actions he had recommended on time
02:33:41 those actions he had recommended on time yes
02:33:42 yes and the need to ensure appropriate resources were allocated to do for doing so
02:33:47 so for the risk assessor to say to describe resources or to warn the the responsible person resources were a problem i see resources as a responsible
02:33:58 problem i see resources as a responsible person's issue yeah
02:34:00 yeah i see
02:34:03 i see can i then turn to a different but different topic but one related to the last answer or last set of answers and that's risk rating matrix now at uh if we can go to blarp
02:34:17 now at uh if we can go to blarp 25027
02:34:19 25027 this is chapter 8 of your report i'd like to look at pages 489 and 490. and on those pages we see table 20.2 and there it is
02:34:30 and there it is where you've provided your own assessment of the risk using the past 79 method
02:34:36 method and classifications yeah yes i've provided i said i was working within um the approach taken by mr stokes indeed yeah it it in indeed
02:34:50 by mr stokes indeed yeah it it in indeed you're putting your it's i understand it you're
02:34:53 you're you're doing what you should have done no not not not it's not my personal fire risk assessment for grenfell tower but i took his approach
02:35:05 but i took his approach and the risk the the the the factors that contributed to his risk level and i thought about the accuracy of what he
02:35:16 thought about the accuracy of what he had recorded in his risk assessment and i tried to show where they increase or discrete decrease one of the parameters yes i understand okay so it might
02:35:27 okay so it might sound technically not relevant but it's different to an independent new fire risk i understand because you might have taken things into account that he did not yeah exactly so i was just trying to show
02:35:39 exactly so i was just trying to show based on
02:35:40 based on what he recorded in his risk assessment where it impacts one of the parameters that contributes to risk that's a
02:35:49 that's a okay
02:35:51 okay yes i don't think it's going it's just a technical point now on that if we go to page 490.
02:36:08 uh you deal with the external wall construction there yeah yeah and you conclude that the risk was intolerable yes yes you see that yeah no i can't see
02:36:20 yes yes you see that yeah no i can't see that so i probably should just explain will i or yes yes yes so in 2016 using mr stokes risk assessment
02:36:31 using mr stokes risk assessment construction was still underway and he still didn't know about control measures during construction if they were needed or not
02:36:38 or not he called that medium so i would put that up to high because he didn't know anything about the control measures and then i've set out the other issues that arose with respect to the harm
02:36:49 that arose with respect to the harm levels
02:36:51 levels on what that causes the risk level to be in 2016.
02:36:58 okay
02:37:02 yes and you
02:37:05 and you you say this in the fourth line stay put policy needs to be changed to total evacuation not possible yeah um is that because
02:37:15 because of your view of the risk posed by the external
02:37:19 external posed by the risk of external fire spread the hazards the results of the cladding yeah so the hazard posed by the external wall and you know as we've discussed at length and its effect on the compartmentation yeah
02:37:31 the compartmentation yeah if you were to undertake the same exercise yeah in table 20.2 yeah again but this time excluding the risk posed by the cladding oh yeah would your classification of the
02:37:42 yeah would your classification of the resulting risk differ do you think yes and also um i think it's important to be clear that i would have made up my business to find out
02:37:51 out the control measures in place while the contractor was still in place and i i would want to have dropped high down to medium based on information
02:38:02 high down to medium based on information about the controls that make sense so if you ignored if you took out for whatever reason the external wall construction um
02:38:11 um is it right that you would be left with either moderate or substantial yeah exactly exactly but one way or the other you wouldn't be left with tolerable no one way or the other you wouldn't be left with tolerable but the idea of
02:38:22 left with tolerable but the idea of these things is even if one of the parameters is you know let's say at a higher level you you do some work to try and bring it down to um
02:38:34 down to um through controls so then you can bring your risk level down you don't let it hanging at substantial you know i would want to say if you knew about control measures with the contractor and if you knew this and you
02:38:45 contractor and if you knew this and you knew that i can bring those parameters down yes it's a work in progress yes i see and that i think leads to the next question based on past 79 if we can just go back to that please yeah which is cta
02:38:57 go back to that please yeah which is cta 703 page 98. i just want to look at page 98 again which is the fra template yeah um that includes there a section for fire risk assessor to
02:39:09 fire risk assessor to to set out the anticipated assessment of the resultant risk once the actions identified in the plan are taken into account and
02:39:21 and you
02:39:23 you you can see that
02:39:27 that uh
02:39:30 the different risk levels are set out yeah and the the count so the so the there's the five levels and then the texts beside us are to do with
02:39:41 texts beside us are to do with actions and time scale yes yeah
02:39:49 now mr state it's right i think isn't it that mr stakes didn't include this um approach if you like or certainly not part of this template in any of his fras
02:40:01 part of this template in any of his fras or his action plans do you mean this text here the action and timescale text the the this text here um i know he didn't i'm just can we not just open up the tape his table he
02:40:14 not just open up the tape his table he didn't
02:40:15 didn't but he didn't but he did use he used the risk estimator yes the five category he did but but what he didn't do i think was to set out the anticipated assessment of
02:40:26 set out the anticipated assessment of the resultant risk once the actions identified have been taken into account or dealt with i should say yeah no that's correct yes yeah uh and let's pin this back to your report yes
02:40:37 let's pin this back to your report yes if we go to blarp 250 27 pages 205 to 206 um and look at paragraphs eight nine point eight point twelve oh yeah yeah
02:40:50 um you you you set out at 11 that part of the action plan yeah and then you say at 12 at the foot of the screen
02:40:59 screen there there is therefore an important difference between hamas to stake sets out his record of significant findings and action plans and how past 79 defines them which is with a clear acknowledgement of how it reduces the
02:41:10 acknowledgement of how it reduces the risk and to what risk level yeah exactly key difference revolves around the purpose of the actions require being to reduce the risk to tolerable or trivial yeah
02:41:21 to tolerable or trivial yeah and then you you go on to say i'll just read the rest to you well then mr stakes is carrying out step nine of his 11 step methodology in formulating an action plan with the aim being to reduce the fire risk from the significant findings
02:41:33 fire risk from the significant findings with both physical and procedural controls the state does not explain the purpose of the actions nor how they were deemed by him to impact the risk classification because mr stokes only ever classified grenfell tower as
02:41:44 ever classified grenfell tower as tolerable without making that assessment dependent upon the completion of the action plan technically this meant that he deemed no actions were necessary or else maybe he meant those actions were needed to maintain the risk level act
02:41:55 needed to maintain the risk level act tolerable
02:41:56 tolerable in the event those actions were not dealt with as which as i go on to show was a regular occurrence over the years in grenfell tower then that risk level was not an accurate one yeah in fact mr stakes regularly classified his actions
02:42:07 stakes regularly classified his actions as high priority closeout in two to three weeks yeah and then you conclude at 18
02:42:13 at 18 this his failure to connect the actions required to a potential consequence for the relevant persons in his technical method and more importantly his failure to communicate the connection to consequences in its documentation was a
02:42:25 consequences in its documentation was a significant one yeah now my question is why was it a significant one
02:42:39 because because of the two points i've just made there that the the the consequence to the relevant person so the harm level because are we able to go back to the risk
02:42:50 are we able to go back to the risk estimator table i'll just use that where it has probability on the left and consequence on the top and the risk levels in the matrix are we able to put that up uh yes uh that okay just in your
02:43:03 that up uh yes uh that okay just in your what your table no no in person yeah it will be here and so it's the cta 703 page 98.
02:43:17 um and go oh it's not that one it's okay don't don't worry about it it's okay so uh let's go back to the text you asked me about is this might help to show you page 97 then
02:43:30 might help to show you page 97 then perhaps that's the better approach yeah perfect right got it yeah lovely lovely so
02:43:36 so um
02:43:38 um you can have the same risk level from a different probability of currents and a consequence of failure okay
02:43:50 and a consequence of failure okay so
02:43:52 so um
02:43:54 depending on the type of depending on the type of harm the grading of harm and depending on the likelihood you can end up at the same risk level but the harm levels are different
02:44:06 harm levels are different okay
02:44:07 okay yes does that make sense so there's another matrix that shows that a bit better
02:44:12 better um
02:44:13 um so
02:44:15 so when you don't explain the harm level caused by particular hazards and why the actions are needed to deal
02:44:26 and why the actions are needed to deal with either the harm or the probability it's very difficult to establish that the meaning you know the true meaning of the risk level and its effect on the relevant persons okay
02:44:37 relevant persons okay and we've talked at length about the idea of an action is it it's either to deal with the probability so you know dropping back down to low
02:44:48 down to low or you're trying to bring the harm potential down so it's very express and obviously a parameter that impacts harm can be more important for example than
02:45:00 can be more important for example than an
02:45:01 an action that may be dealing with probability depending on the circumstance and just to try to explain that to to people perhaps less familiar with yeah sorry yes with risk analysis than you
02:45:12 sorry yes with risk analysis than you are you you i think saying that you can have a high risk a high chance of
02:45:18 of the likelihood of fire resulting in slight harm exactly you can also have a unusually low likelihood of fire but it breaks out would result in extreme harm exactly
02:45:29 exactly okay
02:45:30 okay so that's why the the actions their time scale their their priority and being clear on you know why they're relevant to the
02:45:42 relevant to the final risk level and the parameters driving that risk level are so important for the responsible person to know
02:45:55 now can we go back to past 79 again uh
02:46:00 uh and look please at cta 503 page 60. this is clause 19 2
02:46:07 which is where we go next and it says under 19 2 the action plan should be such as to ensure that if implemented it will reduce fire risk too or maintain yeah fire risk at a tolerable level
02:46:19 yeah fire risk at a tolerable level and your in your report you say and i don't think i need to take you to it for reference purposes it's blarp25027 page 59 at uh paragraph 5.5.10
02:46:33 page 59 at uh paragraph 5.5.10 you say the input of actions to the previous action plan and to the new action plan is critical as in either case it is a record as to whether the implementation of the action plan would reduce fire risk to or maintain it
02:46:44 maintain it at the following level trivial or tolerable yeah um could you just explain why the the exercise is critical as you say well i think it's as i've just described it so it's your previous yeah i think so
02:46:56 it so it's your previous yeah i think so yeah right now mr stokes told the inquiry uh um
02:47:02 um that his description of the fire risk at grenfell as tolerable related to the status of the premises before or after the actions were carried out and he says that in essence that the premises risk rating
02:47:14 in essence that the premises risk rating for grenfell tower would have been tolerable both before and after the identified actions were carried out had they been carried out um
02:47:24 um what do you make of that i i don't really under well i don't really understand that what that means let me show you maybe i mean then if it was
02:47:35 show you maybe i mean then if it was tolerable whether or not the actions occurred then probably the actions weren't required in the first place but i might be taking it a bit too far
02:47:46 lest i am at risk of um misquoting mr stokes let me show you what he said it's day 137 page 50 at line 16.
02:48:00 uh the question at line 16 picks up
02:48:07 uh in the second sentence past 79 suggests that the tolerable box is ticked so as to maintain or reduce the level to what is ticked so the aunt is the answer that it is only once as i
02:48:18 the answer that it is only once as i think you say the actions are completed that the risk is tolerable answer in the particular case here before they were tolerable the actions would still make the building tolerable when it's completed as well
02:48:30 completed as well um now now that that is what he he um said
02:48:35 said uh perhaps we ought to go on to the next question and answer uh
02:48:41 uh well does that tell us that even though there are a number of red and amber items it doesn't matter go on over the page to the risk level or to the risk to life level whether or not they're completed
02:48:51 completed answer in this particular case the risk level is broad enough to include tolerable within those right uh now with that extract in mind would you expect a reasonably competent
02:49:02 would you expect a reasonably competent fire risk assessor to calculate the risk to
02:49:05 to a building at the same level both at the time of the assessment as it stood and putatively after the actions identified within the action plan had been carried out
02:49:16 i think no no
02:49:24 given mr stakes's assessment of the risk for grenfell tower as always tolerable yes should the number of high priority actions have been an indication
02:49:35 priority actions have been an indication to the reasonable or reasonably competent fire risk assessor that the risk presented was in fact greater than tolerable
02:49:42 tolerable not least because the number of actions tended to suggest the lack of adequate controls
02:49:47 controls apply to one or more significant fire hazards yes that's correct and thus a high risk likelihood of fire potentially yes yeah exactly depending
02:49:58 potentially yes yeah exactly depending yes depending on the severity of the priority item we're discussing but it yes it changes the risk level thank you yeah now dr lane i've come to the end you'll be glad to hear of my questions
02:50:10 you'll be glad to hear of my questions for you oh russia okay it's customary at this point for us to take a break yeah uh and see if there are any questions which others outside this room or perhaps inside this room have for us
02:50:21 perhaps inside this room have for us i'm going to ask the chairman um perhaps too for us to take a a a short break because i'm quite keen not to keep you here over the lunch break if possible well i just thought quarter now would be long enough wouldn't it uh i would think
02:50:33 long enough wouldn't it uh i would think it is probably long enough if if we were to say
02:50:36 to say well i'm going to what i think i shall say is that we'll come back at quarter to one yes okay unless you send a message to the effect that more time is required that's very sensible thank you all right yeah we'll take the usual
02:50:48 all right yeah we'll take the usual break at this point yep okay and we'll come back at quarter one okay thank you thank you very much
02:51:02 well as i say we'll come back to one unless you tell us otherwise thank you mr chairman yes thank you
03:07:07 good would you ask dr lane to come back in please
03:07:19 right doctor lamar should we see if mr millett's got any more practices for you thank you mr chairman dr lane you will be delighted to hear that i have no further questions for you okay and it
03:07:30 further questions for you okay and it therefore remains for me to thank you very much for coming here to the inquiry and assisting us with your expert opinions we're extremely grateful to you uh um and obviously there are
03:07:41 uh um and obviously there are further matters to be explored with you later in this inquiry module seven in relation to the aov system yes but subject to that we're very very grateful for your views on the matters
03:07:52 grateful for your views on the matters arising in module three okay thank you dr lane is right that i should thank you on behalf of all the members of the panel we found your evidence very interesting very illuminating and we're
03:08:03 interesting very illuminating and we're very grateful to you for the amount of work that's gone in to the very substantial reports that you've prepared yes so thank you very much indeed yeah and we'll look forward to seeing you again in due course
03:08:14 again in due course thank you thank you anyway you're free to get now
03:08:25 right mr minute well is that it for today mr chairman it is it for the day and i should also say that subject to dr lane's views on uh aov and further evidence potentially
03:08:36 uh aov and further evidence potentially about that that is all the evidence for the inquiry for module three well thank you very much so we will stop at that point for today
03:08:47 stop at that point for today and we'll resume on monday at 10 o'clock monday 10 o'clock when we shall i think here's some closing statements yes not for modules one and two correct good
03:08:59 for modules one and two correct good thank you very much well then 10 o'clock next monday thank you very much