Dr Barbara Lane gives detailed evidence on fire risk assessments for Grenfell Tower, criticizing Carl Stokes's FRAs for failing to identify disabled residents, lacking proper emergency plans, and mischaracterizing lifts as firefighting-capable.
00:00:28 yes would you ask dr lane to come back in please thank you
00:00:37 [Music]
00:00:43 all right dr lane ready to carry on yep very good thank you yes mr nelly when you're ready yes mr chairman thank you um
00:00:50 um dr lane at day one three seven page one two three paragraphs five to eleven uh mr stakes accepted in his evidence that in the five fire risk assessments that he conducted for grenfell tower between
00:01:03 he conducted for grenfell tower between 2010 and 2016 he never identified and considered disabled residents or occupants especially at risk now
00:01:12 now if that is correct as he says was that failure to identify any vulnerable residents consistent with your expectations of what a reasonably competent fire asked assessor should
00:01:23 competent fire asked assessor should have done no thank you would you expect the competent advisor within the responsible person to note that there were time and again for a
00:01:35 that there were time and again for a period of years no specific disabled residents or occupants at risk identified in any of those fire risk assessments yes yes and would you expect the competent
00:01:47 and would you expect the competent person within the responsible person to ask the fire risk assessor to correct the fire risk assessment in that respect or to do further work yes but and particularly when the risk
00:02:00 yes but and particularly when the risk assessment tackles us in writing yes particularly so particularly can i then turn to the assessment of the emergency plan at grenfell town such as it was and you've covered this
00:02:11 such as it was and you've covered this topic at chapter nine in your report at blarp25028
00:02:17 and particularly section one yeah on pages five to eight of that um in in very simple terms is it your opinion that article 15 of the rro
00:02:28 the rro imposes the basic obligation on the responsible person to have an emergency plan for its building that's my understanding based on reading um
00:02:39 um i think it's particularly in the enforcement guide so i've had to refer to other
00:02:44 to other documents to be clear on that yes and you've said so and when you say enforcement guide what do you mean oh sorry um
00:02:51 sorry um i mean the document issued by the odpm in 2007.
00:02:57 in 2007. right so the dclg guide to the rro yes sorry excuse me yeah i have given the correct reference in my report right yeah and other documents i've had to
00:03:08 yeah and other documents i've had to rely on and i've set them all out in the the big table at in in chapter nine you have and one of those documents i think is the sleeping guide yes yes can we look at that rbk3036722
00:03:22 page 36
00:03:26 and that page 36 we find section 4.2 of the sleeping guide and if we look at that at the very bottom of your screen it says emergency plans you need to have an emergency plan for dealing with any fire situation the
00:03:39 for dealing with any fire situation the purpose of an emergency plan is to ensure that people know what to do if there is a fire and that the premises can be safely evacuated yeah um and you quote that in fact in your
00:03:50 and you quote that in fact in your report at paragraphs 2.2.5 blarp 250 28 page 9. presumably presumably well let me ask it this way was that a principle which as f so far as you are aware was in was in common
00:04:03 as you are aware was in was in common currency uh but in the years 2010 to 2017
00:04:08 2017 in common currency but commonly understood so
00:04:11 so you know that i work in lots of different sectors so
00:04:16 so the emergency plan is whatever
00:04:19 whatever common currency as you say in many of the sectors that i work right and is it right that the findings from a fire risk assessment are a key
00:04:30 are a key driver or influence of what should go into an emergency plan as contemplated here
00:04:36 here sorry can you just say that again that the findings of the risk assessment yes um
00:04:41 um yes they they're inextricably linked to yes
00:04:45 yes and
00:04:45 and is it right or is it your understanding that an emergency plan had to be building specific yes yes
00:04:54 yes yes uh and documented yes
00:04:57 yes um in all of your work producing your report did you see any evidence of an emergency plan such as we've just been discussing as contemplated by the sleeping guide for
00:05:09 contemplated by the sleeping guide for grenfell tower in in the context no no i did not not no
00:05:17 no no just pausing there would it be normal practice for a responsible person to have no emergency plan at all for a building no
00:05:29 no can i then turn to the question of grenfell tower itself whether it was a simple building or a complex building yeah
00:05:35 yeah can we start again with the lga guy say again go back to the lga guide h aom three zeros four five nine six four page one one eight can we go to paragraph 79.1
00:05:51 and this is under the heading preparing for emergencies and 79.1 says this it is a requirement of the fsa that there should be a suitable emergency plan for the premises rarely in purpose built blocks
00:06:03 premises rarely in purpose built blocks of flats will it be necessary to have a more elaborate emergency plan than a simple fire action notice see appendix 5 for examples nor will it be universally necessary to display such notices indeed
00:06:14 necessary to display such notices indeed it is more common not to display notices but to convey this information to tenants in other ways eg through residents handbooks and so forth now in terms of the responsibilities in
00:06:26 now in terms of the responsibilities in in relation to the emergency plan first it was it your understanding that the responsible person should prepare and maintain that plan
00:06:36 or or employ someone to do so yes yes and and was it then the fire risk assessors task to review the suitability of that plan as part of their fire risk
00:06:47 of that plan as part of their fire risk assessment yes or they might even be asked to you know they might be scoped to write it yeah yes and that's a contractual matter though yes indeed and then if we go to page 120 in this document
00:07:00 page 120 in this document can we look at paragraph 79.12 just next to the uh premises information box a photograph of it it says this in large more complex box of flats it can be of great assistance to the fire and rescue
00:07:12 great assistance to the fire and rescue service to keep plans on the premises detailing information on the layout of the building and its services this can be helpful at the time of an incident in dealing with a with the emergency again use of a premises information box at the
00:07:24 use of a premises information box at the main entrance is one way to achieve this now you can see the reference to large more complex blocks of flats yeah is there was there an an accepted or
00:07:36 is there was there an an accepted or common definition of or standard of what is a complex block or was that simply a matter of fact and degree for the judgment of the fire risk assessor and the responsible person i think
00:07:47 think back then so before the fire i would have said it was um
00:07:54 um you know it's not something i thought about very often in i think back then i probably imagined it was judgment i think i have to be honest that i've learned
00:08:03 learned in the last few years that there's some complex views around the subject but i it's not something that i came up against let's say before grantful right
00:08:15 against let's say before grantful right okay um to the best of your knowledge and understanding and experience [Music]
00:08:21 [Music] how would a an average fire risk assessor reading
00:08:26 reading 79.12 know whether the building with which they were confronted was a more complex block of flats what makes it more complex so i think i
00:08:39 what makes it more complex so i think i you know i've set that out a few times actually i think a module two and again in this module complexity is a function of
00:08:50 complexity is a function of the systems made available in the building for protection if there's more than sleeping risk and also it's my you know it's also a
00:09:01 and also it's my you know it's also a function of the occupancy profile of the building
00:09:04 building so all the standard issues
00:09:09 issues that have to be contemplated in fire safety either during design or in occupation when
00:09:17 when carrying out a risk assessment as well so they're like the classic protection the classic occupancy profile issues that's how you work out a building is complex or not
00:09:28 and i've given you know i've set out a list of things i just can't remember it off by heart right now um
00:09:35 um i did provide a list of really specific things you you we'll look at part of that in a moment before i do can i just ask you to be shame what mr todd said in his evidence yeah
00:09:45 yeah um
00:09:47 um at
00:09:48 at day 167 if we can please turn that up page 144
00:09:53 page 144 line nine i'll just show you what he said yeah
00:09:58 said yeah line nine line nine yes uh he said there isn't a definition of complex block of flats but i wouldn't have regarded it as grenfell tower as complex and here's the reason why from the fire brigade
00:10:09 reason why from the fire brigade attendance point of view and this is what it's talking about here could the fire brigade easily get disorientated with multiple staircases corridors of corridors and so on and so plans would help them the floor plan on every floor
00:10:20 help them the floor plan on every floor of the uppermost floors of grenfell tower simply repeated and it was a very simple layout and there was a single staircase in a single lift there was a smoke control system which you get in blocks of flats but i wouldn't have called it a complex building sir no
00:10:33 called it a complex building sir no you wouldn't not for the purpose of this paragraph no yeah so i understand the additional like the the points mr todd has raised there that don't apply to the physical layout of
00:10:44 don't apply to the physical layout of grenfell tower i i agree that they are introduced complexity i mean
00:10:51 i mean you know
00:10:53 you know it may be because i find it so incredibly difficult to work out lots of the systems and things that were installed in grenfell tower that i can't agree the smoke control
00:11:05 that i can't agree the smoke control system is incredibly complex and was provided with all sorts of interventions by the brigade that i've explained that i don't think are simple i understand there is a single staircase
00:11:18 i understand there is a single staircase but for example it's not in the in the typical arrangement you know the riser isn't in the classic position there's a few other things like that i understand that lots of people
00:11:31 i understand that lots of people consider blocks of flats simple i understand that but my opinion is that i i
00:11:41 i i can't
00:11:42 can't share that opinion any longer now can we look at chapter nine of your report blarp 25028 page 14.
00:11:52 and on page 14 let's look at paragraph 2.2.20
00:11:56 2.2.20 yeah
00:11:57 yeah and you say here grenfell tower was a high-rise high-rise building with a shared single means of egress and multiple occupancy types residential and non-residential the emergency plan for
00:12:09 non-residential the emergency plan for such a building would cover the residential portion of the building on upper levels as well as commercial tenancies on the lower levels including a boxing club and a nursery grenfell tower was provided with a complex smoke control system and its
00:12:21 complex smoke control system and its occupancy profile contained residents who required assistance in the event of a fire as well as non-residents and other relevant persons on this basis as i've set up before in my phase 2 module 1 report
00:12:33 my phase 2 module 1 report under regulation 38 i would consider grenfell tower to be a complex building and i review the requirements for the emergency plan accordingly yeah um
00:12:43 um just to be crystal clear are the factors that you've set out there paragraphs 2.2 23 and 2.2.24 the factors that in your view make grenfell tower a more complex block for
00:12:55 grenfell tower a more complex block for the purposes of the lga guide oh for the purposes of the lga guide which refers to more complex buildings as we've seen
00:13:05 i i think there are the parameters i consider to make it complex yes in your opinion could a building with the profile you've identified here um be ever be considered a simple building
00:13:20 well i've told you i think other people think that's simple but i i mean you don't i don't i think i've made that point yeah now um janice ray
00:13:31 janice ray uh told us that she didn't think or she didn't agree that grenfell tower was a complex building she said that it was never considered a complex building as a result of a fire risk assessment and not considered to be
00:13:42 risk assessment and not considered to be complex by the lfb either that was her evidence okay my question is in your opinion would it be apparent to the reasonable competent advisor within the responsible person
00:13:53 advisor within the responsible person that the grenfell tower was a complex building
00:13:56 building so i don't understand that point that you've relayed back to me because my understanding is that miss ray in consultation with mr stokes
00:14:07 miss ray in consultation with mr stokes and the enforcing authority created a list of high-risk buildings in the wider kctmo portfolio
00:14:19 in the wider kctmo portfolio and i don't understand why um that doesn't mean some element of complexity are fully okay they split their portfolio
00:14:30 portfolio into three and they placed grantful tower into high risk
00:14:36 risk so in my mind where we've we've entered into a space of complexity i see okay do you criticize mr stokes for not concluding that grenfell tower
00:14:47 for not concluding that grenfell tower was a complex building and therefore advising
00:14:52 advising the tma that a comprehensive emergency plan should be developed oh i see what you mean i uh yes but i i mean having read everything it just was never something that was
00:15:03 it just was never something that was even contemplated over the years okay so it's not relevant to grantful but theoretically if a client hands you the list of high-risk properties on their portfolio
00:15:16 high-risk properties on their portfolio and you see some of the features here i've listed i i think it's reasonable to place it into the complex category and on that basis do you criticize mr
00:15:28 and on that basis do you criticize mr stokes for not advising the tma that they should have a comprehensive emergency plan for grenfell tower well i think he should have advised them that they needed an emergency plan
00:15:39 that they needed an emergency plan anyway
00:15:41 anyway probably i wanted to be more precise that way right yeah and
00:15:47 and you say that regardless of whether it was complex yeah because because because the the kind of format and contents of the emergency plan then change as a function of simple up to complex my
00:15:59 function of simple up to complex my understanding of particularly the guidance and the guidance is not you do emergency plan if the building is complex and you don't do anything at all if it's simple i don't
00:16:10 anything at all if it's simple i don't understand that to be the case the the detail you have to get into is what changes for what kind of building would you reasonably not do an emergency plan i can't personally i can't imagine
00:16:22 plan i can't personally i can't imagine any building where you wouldn't have to have some
00:16:26 have some thought having gone into what happens in the event of a fire then turning to the question of the format of an emergency plan you've covered that i think in chapter 9 of your report yeah a page 30
00:16:37 chapter 9 of your report yeah a page 30 uh you've referred there to annex g of past seven oh yes yeah 2013. yeah um let's just um look at that so just have it on the
00:16:48 look at that so just have it on the screen so people can see what we're talking about it's bsi 6071
00:16:54 6071 page 39.
00:17:02 this is alex g of past seven from 2013
00:17:07 from 2013 uh would you expect both the responsible person perhaps through the competent advisor and the fire risk assessor to be familiar with this template here nxg yeah so i i would
00:17:21 this template here nxg yeah so i i would never criticize anyone about a template i've said that before okay but i i i think i think there's all sorts of documents make clear the emergency plan is is a
00:17:34 make clear the emergency plan is is a duty for the responsible person and this you know i think actually this is kind of a helpful pro form if one wasn't sure of what to do it it it offers you some help along with
00:17:47 it it it offers you some help along with the big list and the hm sleeping guide particularly yeah and would you expect the
00:17:52 the uh competent advisor within the responsible person and the fire risk assessor to be familiar with the guide and at least the principle of having an emergency plan as indicated by nxg here
00:18:03 emergency plan as indicated by nxg here so do you mean do i think they should have been familiar with past seven expressly yes i mean
00:18:10 i mean i i i just i'm probably aware that it wasn't so well used okay
00:18:16 okay and but i don't think that detracts from knowing
00:18:21 knowing about the duty to have some form of emergency plan
00:18:36 now can we then turn to the tmos emergency plan itself and you've covered that in chapter 9 of your report
00:18:46 if we look at it it's a tma1001 3898.
00:18:51 3898. let's just have that up please on the screen
00:19:02 tmo1001 3898
00:19:10 that's that is the first page um and to remind people of its dates can we go to page three
00:19:18 version one you'll see was produced in august 2004 yeah and then there were later revisions in may 2009 may 2015 and february 2016. yeah
00:19:32 and there's an index on page five if we can then
00:19:35 can then switch to
00:19:36 switch to that you'll see that there yeah uh
00:19:42 uh and then on pages 13 to 14 we just look at that you can see from 13 and 14 you can see that there's an emergency plan which sets out guidance on how the
00:19:54 which sets out guidance on how the emergency plan can be found and used yeah
00:19:57 yeah and you'll note that the first
00:20:01 first part of that after the introduction kctma emergency plan deals with what the kctma should do in the event of a major incident yeah which is uh defined
00:20:13 which is uh defined and a major emergency which is also defined
00:20:17 defined and then if we turn to page 17 there's a diagram with a cascade cascade one for key individuals to be contacted in the event of an emergency and on page
00:20:28 in the event of an emergency and on page 19 you can see there's a cascade 2 yeah about what happens outside normal working hours and who contacts whom and yeah the rotors etc and some individuals
00:20:39 yeah the rotors etc and some individuals the names of whom are now fairly familiar to people just looking at the overall doc nature of this document and the date of its original creation in 2004
00:20:49 2004 yeah which i think is is this right before the rro came into force yeah um is it
00:20:56 is it do you have an opinion about whether it was prepared in compliance with the rro or for some other purpose well i i try i tried very hard to work out if it had features of a plan
00:21:08 out if it had features of a plan um
00:21:09 um that was relevant to communicating matters in the event of a fire and and i wasn't able to conclude that as i sat out in in chapter nine
00:21:20 nine and in the end i decided it was for other purposes yes but it's for others to you know indeed make nothing yes if we go to page one four five we can see a specific
00:21:31 can see a specific entry i can call it that for grenfell tower
00:21:35 tower yeah you can see it there yeah lancaster west and there's some detail about that yep number of dwellings 120 numbers of residents yeah uh and other matters you can see that on
00:21:46 uh and other matters you can see that on page 146 it continues um are you you're familiar with this oh yeah incredibly familiar yep and you've noted in your report at paragraph 8.2.17
00:21:59 paragraph 8.2.17 at blarp 250 is 28 page 92 that this entry was not updated after the completion of the refurbishment in july 2016. or indeed before that yeah
00:22:10 2016. or indeed before that yeah um now this is laying the groundwork um
00:22:15 um janice ray was asked if the emergency plan was intended to be building specific
00:22:19 specific for grenfell and what she said and it's day 142 yeah page 43 lines 22 to 25 i'll just recite it to you she said it was intended to collate relevant information that the emergency services or anybody else would
00:22:31 emergency services or anybody else would require so it was meant to be a source of information and contribute to emergency planning that's like that's how she described okay this document yeah in your opinion did this emergency
00:22:42 yeah in your opinion did this emergency plan
00:22:43 plan such as it was for grenfell tower collate relevant information necessary for the fire and rescue service to respond to a fire at grenfell tower oh yeah so it had
00:22:56 so it had some pieces of information and some of those pieces of information were obsolete the night of the fire and i didn't find any evidence of it being a let's say a working
00:23:09 of it being a let's say a working document or a communication doc you know a document to communicate with the brigade before the fire because you know there was a formal
00:23:20 you know there was a formal again a really productive system available to the kctmo where they were meeting um
00:23:27 um the brigade in various forms it was meant to be i think it's every two months or so so
00:23:33 so i i did look again to see how this document was used and kept up to date in that context as well and i didn't find any evidence of it right did these pages of this document
00:23:44 did these pages of this document relating to grenfell tower in your opinion satisfy the requirement of article 15 of the rra
00:23:52 now let's then look at carl stokes's assessment can we go to past 79 again please cta 703
00:24:04 past 79 again please cta 703 this time page 90 section 25.4
00:24:14 and we can see on that page uh this is part of the template and making all allowances for what you've said so far about templates uh you can see here that there is a
00:24:27 uh you can see here that there is a section on appropriate fire procedures in place yep um and there's some questions that are set out six questions are procedures in the event of fire
00:24:38 are procedures in the event of fire appropriate and properly documented etc uh looking at those questions would it be normal and accepted practice for a fire risk assessor to examine the arrangements for an
00:24:49 to examine the arrangements for an emergency plan for a building which he was assessing by reference to this list
00:24:56 this list i think yeah i think it's a very helpful list yes yeah or if he had an extended list or he went to one of the longer lists and the sleeping guide but yes yes and
00:25:06 and similarly would it be uh
00:25:09 uh normal practice or good practice let's say for a fire risk assessor to check that there was a documented emergency plan recording these arrangements yes i think so yes oh sorry i should have just said yes yes
00:25:21 sorry i should have just said yes yes and also to check that there are adequate procedures for evacuation of any disabled people likely to be present which is the last question set out there yes yes and would failure to do any of
00:25:32 yes yes and would failure to do any of those things to assess to document or to check there was a document and to make the check for disabled people be consistent with reasonable competence to failure to do so it's not consistent
00:25:45 to failure to do so it's not consistent with reasonable competence and not knowing the answer to those questions
00:25:50 questions or not either not having been able to find or not have read documents that allowed you to answer those questions impacts your ability to conclude on a risk level
00:26:02 risk level that's the more important point if you will
00:26:05 will yes
00:26:07 yes do you agree that this text in this guidance tells the fire risk assessor regardless of peeps the the the the approach set out here was that there
00:26:18 the approach set out here was that there did need to be procedures in place for the evacuation of any disabled people identified as likely to be present yeah that yes that's my understanding yeah and was it your
00:26:29 understanding yeah and was it your understanding that the approach in past 79
00:26:33 79 was that these procedures were not simply reliance on the fire and rescue service to get people out of the building but procedures to be put in place by the responsible person yes yes
00:26:44 person yes yes and the presence and adequacy of those procedures in place if they were in place uh fell for assessment by the fire risk assessor yes
00:26:54 yes and on the evidence that you've seen can you tell us what were the tma's procedures for the evacuation of disabled residents of grenfell tower as contemplated by that final question on that page there
00:27:09 in practice nothing
00:27:12 as documented in the risk assessment something different
00:27:18 do you know the the the language and the risk assessment by which do you mean the reference to the tp tracking yeah and and disability and there was a section so
00:27:29 disability and there was a section so because the risk assessment is a formal document and the emergency plan emanates from from it but my understanding having reviewed all the evidence is there was no procedure
00:27:40 the evidence is there was no procedure at all
00:27:41 at all thank you now can we then uh
00:27:45 uh go
00:27:48 yes can we then go please too uh cars takes his fra for the 20th of june 2016. his last one cst full zero is three one four five page five
00:28:00 um and on page five under the heading evacuation strategy for this building yeah
00:28:06 yeah he says this and i'll read it all to you it's a bit long but please bear with me and for the residents of this building there is a state evacuation strategy this means the residents can remain within their own dwelling during a fire
00:28:18 within their own dwelling during a fire incident in this building unless the fire is in their dwelling or that their dwelling is otherwise affected by the fire in which case they should immediately evacuate their dwelling and call the fire and rescue service the
00:28:29 call the fire and rescue service the fire service or or tmo employees will arrange for a general evacuation of the whole building at any time if this is appropriate to do so alternatively the resident can leave their dwelling at any
00:28:40 resident can leave their dwelling at any time if if we turn the page they so wish to do so tmao has provided information to all residents in tenants handbooks by letters and briefing sheets of what to do in the event of an emergency and
00:28:51 do in the event of an emergency and articles on fire safety advice and emergency procedures are included in the residence magazine called link also articles are provided reminding tenants that they must not store items in communal areas nor cause obstructions to
00:29:03 communal areas nor cause obstructions to the means of escape these articles are produced in the seven major languages which have been selected as being the most likely to meet the needs of resident of the residence the landlord relies upon the tenants to respond to
00:29:14 relies upon the tenants to respond to any emergency in accordance with agreed emergency plans and does not facilitate any fire drills in other emergency evacuation exercises in the residential area of this building there have been no fires in the last two
00:29:26 there have been no fires in the last two years apart from the burnt cooking toast incident in the last week of september 2014 the fire service were called to this tenth floor level flat by the occupant as far as i know no firefighting action was taken by the
00:29:37 firefighting action was taken by the fire service i have been told and there is no known problems with false alarms from the domestic detectors installed within the individual dwellings and then he's got a section for other areas of the building and you can see there the
00:29:49 the building and you can see there the contractors will have an evacuation policy and he's got something about the nursery and boxing club having their own fras
00:29:56 fras now um
00:29:58 now um in evidence carl stokes told us and for our purposes this is day one three six page two one five lines twenty two twenty five that this this section of his fra that i've just read to you his fire risk assessment that i've just
00:30:10 his fire risk assessment that i've just read to you would contain the specific evacuation strategy for grenfell tower in two parts one for the residential areas and one for the commercial or retail areas now that was his evidence in your view
00:30:23 now that was his evidence in your view dr lane bearing in mind the nature of the obligation and the guidance we've looked at did carl stokes his assessment of the emergency plan for grenfell tower set out here meet the standards expected
00:30:35 set out here meet the standards expected of a competent fire risk assessor no it didn't because it's inaccurate it's an inaccurate description of the arrangements made
00:30:47 arrangements made inaccurate
00:30:52 i think maybe do you mean if if this just this page could be considered a compliant emergency plan if it contained accurate information
00:31:03 it contained accurate information we've agreed i think there was nothing else that you've seen by way of an emergency plan exactly and then this information um is also incorrect right because of
00:31:15 um is also incorrect right because of the offer of the general evacuation of the whole building and i found no procedures to enable that
00:31:28 now i want to turn to a totally different topic which is lifts and can i begin with mr stokes's understanding of lifts as far fighting lifts in the face of well
00:31:40 in the face of well in the context of the information that he was given yeah that this is where we're going now in your phase one report at appendix l i'll just give the reference it's blas
00:31:51 reference it's blas 6033 but also in paragraph 12.2.4 of chapter eight of your phase two fra report blr blarp25027252
00:32:05 you set out your conclusions i think on the degree to which the lifts at grenfell tower did or did not conform to the applicable standards what i want to try to do is summarize your view if i
00:32:16 try to do is summarize your view if i can yeah briefly just tell me if you agree with this summary first
00:32:21 first is it right that your view is that although the passenger lifts complied to the lower standard of fire lift defined by cp3 1971 they were not firefighting lifts
00:32:34 it's yeah it's my understanding there were not firefighting lifts and that they didn't conform to the standards required by bs 55885 of 2004 and bs en 8172
00:32:48 55885 of 2004 and bs en 8172 yep that's correct because for example there was no escape hatch or dual power supply particularly because of the dual power supply yeah now
00:33:01 power supply yeah now and as a result it's your view i think that the lower level of protection afforded by a fire lift meant that they must not be used for human transport during a fire yes yes
00:33:12 human transport during a fire yes yes and therefore it would follow that fire lifts
00:33:15 lifts such as those at grenfell tower should not have been relied upon for the evacuation of residents within any evacuation strategy that's correct thank you now let's then look against
00:33:27 thank you now let's then look against that background of summary of your view mr stokes is june 2016 fire risk assessment go back to paid go back to where we were page five cst four zeros three one four five page five
00:33:40 three one four five page five we looked at this a moment ago we'll come back to it he says there if i um five lines up from the bottom of the box
00:33:50 uh he says uh
00:33:54 uh sorry where are we now are we still on this page
00:33:57 this page uh
00:34:00 yes okay yep
00:34:05 oh yeah sorry i can see it now apologies apologies
00:34:08 apologies yes
00:34:10 yes uh and uh you can see what he says there yeah uh he he says the two lifts in this building both are evacuation straight firefighting lifts yes now he said the same thing in all of his fras from
00:34:21 same thing in all of his fras from grenfell tower despite the fact that he noted the absence of an escape hatch yes and that he had been told a few other times in writing that they weren't uh as well yeah now
00:34:32 can i just pin this down with precision in your report can we go to your report at chapter eight blarp two five zeros 27 page two five eight and let's look
00:34:44 page two five eight and let's look together at paragraph twelve point two point fifty two yep uh you say there uh after reciting paragraph 119 of mr stakes's witness statement yeah
00:34:56 stakes's witness statement yeah that figure of 12.3 you say the absence of a roof hatch is a key indicator a lift is not a firefighting lift and was a requirement of bsen 8172 2003 as i've presented in
00:35:08 of bsen 8172 2003 as i've presented in chapter 7 of this report now you say key indicator would you expect
00:35:15 expect the reasonably competent pharah's gessessa
00:35:17 gessessa during the period 2010 to 2017 to know that the absence of a hat meant that these lifts could not be described as firefighting lifts in his fras yes he
00:35:28 as firefighting lifts in his fras yes he would and therefore also couldn't be used for evacuation of occupants disabled or otherwise yes uh and if you go on to page 260 two pages on in this you go
00:35:41 to page 260 two pages on in this you go on to say
00:35:43 on to say and paragraph 12.2.67
00:35:47 under the heading the resulting failures in mr stakes's advice and assessment of risk to the relevant persons you say mr stokes's continued description of the lift of firefighting and evacuation
00:35:58 lift of firefighting and evacuation lifts noting it is very unusual for evacuation lift to be present even in a modern high-rise building in london create a skewed impression of fire risk control within the building as the fire
00:36:10 control within the building as the fire risk assessment referred to an active fire protection measure that did not in fact exist yes yes we've heard from mr stokes that he believed that the lifts at grenfell
00:36:21 believed that the lifts at grenfell tower were firefighting lifts and that they would satisfy the requirements for evacuation lifts was that belief a significant error or a minor error
00:36:33 minor error it's as i've explained i think it's a significant error was it an error which in your opinion would prevent the fire risk assessment from being considered suitable and sufficient at least to that extent
00:36:45 sufficient at least to that extent yes i would now mr todd has said that it's a minor error in the context of a suitable and sufficient fra and to be clear that's a paragraph 2.69 of his main report of
00:36:57 paragraph 2.69 of his main report of page 18 cta 5011 page 18. okay what do you say about that can i understand did he think the minor error was not knowing it was a firefighting lift
00:37:09 not knowing it was a firefighting lift or that
00:37:10 or that non-firefighting lifts are appropriate for the evacuation of people in the event of a fire just not knowing the type of lift it was yes
00:37:21 yes and he still thought it was a minor error when a risk assessor goes on to rely on it for evacuation myth that's mr todd well that's that much because that's
00:37:32 that much because that's a very important distinction there yeah uh well um so i'm afraid i'd probably i do prefer if mr todd speaks for himself well indeed yeah and that's very fair let's then
00:37:43 and that's very fair let's then uh
00:37:44 uh show you what he said in specifically day one can we have up please day one three seven page one eight three yeah
00:37:54 line fourteen
00:37:58 i'm sorry this is mr stokes is all over that side okay sorry yeah can we just because we flip between those two people a lot which i wasn't expecting no that's my fault yeah this time for confusing the two but mr stakes is all evidence
00:38:10 the two but mr stakes is all evidence first of all uh okay so sorry can we back up is it mr stokes says it's a minor error i am showing you mr mr todd says it's a minor error and mr stokes is uh based on what mr stake says and
00:38:22 is uh based on what mr stake says and i'm going to show you what mr stakes says that i'm going to show you what mr todd says okay because because of the the way you answered the question and needed some help so i'm going to okay apologies all the material yeah um a day
00:38:33 apologies all the material yeah um a day 137 page 183 line 14 yeah mr stokes says uh well i put to him this mr todd says in his report that you made an incorrect assumption that these lifts could be
00:38:45 assumption that these lifts could be used for the purpose purposes of firefighting or evacuation we can see it if you like do you agree with him no
00:38:52 no why is that because under the definition of a firefighting lift and an evacuation lift these lifts could both be used could be used for both these purposes question do you accept that your statement that these were firefighting
00:39:03 statement that these were firefighting evacuation lifts would have misled the reader of this document who wanted to know the
00:39:07 know the evacuation strategy for disabled persons in grenfell town no question you don't and you don't accept i imagine also that your statements posed a risk to life to anyone who sought to use them in that way no
00:39:19 sought to use them in that way no so that that that's his that was his evidence now let's see what mr todd said about
00:39:23 about his uh evidence first of all can i show you his main report cta 6011 page 18 paragraph 2.69
00:39:48 conclusions and
00:39:51 and this is general
00:39:54 any shortcomings in the frees carried out by mr stokes are in my opinion quite minor in the overall context of a suitable and sufficient fra the obvious exception is a statement that would imply that the cladding at
00:40:05 that would imply that the cladding at grenfell tower satisfied the requirements of the building regulations uh in 2010 etc a further exception is mr stakes's assumption that the lifts were firefighting lifts which lie is likely
00:40:16 firefighting lifts which lie is likely to have resulted from an assumption based on information originally agreed between salvas and the tmo in 2009 while not taking into account a change in the position of the tma senior lift engineer
00:40:27 position of the tma senior lift engineer in relation to these lifts in 2011 so he accepts uh
00:40:32 uh that that was an ex that lifts an exception
00:40:36 exception to what he says about uh
00:40:39 uh the character of the era uh
00:40:44 uh uh now if we look at his evidence in in to the inquiry orally can we go please today 167
00:41:02 page 180 day 167 page 180.
00:41:14 and uh
00:41:20 uh uh if we go please to i'm sorry the bottom of page 179 which is where the passage i think i need starts
00:41:32 uh i've shown him paragraph 8.68 of his report
00:41:36 report where i quote to him at line 22 i do acknowledge that because mr stokes believed that the lifts at grenfell tower were firefighting lifts he did incorrectly assume that they were they would satisfy the requirements for evacuation lifts which are lifts
00:41:49 evacuation lifts which are lifts we go over the page designed to be suitable for the evacuation of disabled people in the event of fire but are usually found in commercial buildings rather than block flats when their evacuation lift operator is normally available
00:42:00 available that's correct sir question yes was that belief you've identified there a significant error much less than you might think sir and the reason is that the tmo never had any
00:42:11 the reason is that the tmo never had any intention of sending people to evacuate residents via the lifts that's one reason the second reason is that in practice you don't get evacuation lifts in blocks or flats anyway and perhaps one of the most important reasons that
00:42:22 one of the most important reasons that it's not as significant as you might think at first sight is that if a resident leaves their flat because there's a fire in their flat they can actually use a standard passenger lift to leave the building and he goes on saying now that sounds wrong because and
00:42:33 saying now that sounds wrong because and there's some background to that about the fire brigades union and some history about drafting the lg guide mike my question is um
00:42:45 is um let's break it up in the way which yeah having shown you the background first was it a significant error or a minor error for mr stokes to
00:42:56 or a minor error for mr stokes to believe
00:42:57 believe that the lifts at grenfell tower were firefighting lifts it was a is a significant error for mr stokes not to have made it his proper business to know
00:43:08 business to know which lift was installed in grenfell tower and secondly was it a minor error or a significant error for mr stokes to believe that the lifts at grenfell tower could
00:43:19 that the lifts at grenfell tower could be used to evacuate residents in the event of a fight did you give me major and minor was it it's a major significant oh sorry significant it's a significant error that mr stokes
00:43:31 significant error that mr stokes communicated in his risk assessment the lifts were safe to use for an evacuation now let's look at mr stokes's second witness statement moving this on a
00:43:42 witness statement moving this on a little bit further this is at cst 3030186
00:43:49 and it's his second witness statement i'd like to look with you page 25 paragraph 99 little roman one
00:44:00 and he says in the beginning of paragraph 99 i did not so far as i can recall request further or indeed any independent information regarding the lifts this was because one the lifts
00:44:12 lifts this was because one the lifts were in situ having been installed in 2005 and therefore would have had received building control sign off in 2005 as compliant with the functional requirements of the building regulations this would be so even though they were
00:44:24 this would be so even though they were being installed as lift in an existing building all classed as being modified as opposed to being new lifts in new buildings in 2005. now
00:44:35 uh you can see uh yeah that yeah i i i think i i that just doesn't have any meaning to me well my question
00:44:46 have any meaning to me well my question was
00:44:47 was is what mr stokes said there a valid assumption no now if we go to your report if i'm not sure we need to go to it we just cite it you say in chapter 8 of your report at
00:44:58 you say in chapter 8 of your report at page 258 of blarp25027
00:45:02 paragraph 12.2.49 that mr stokes made no assessment of the compliance status of these lifts during his fra work at grenfell tower at any time yeah
00:45:13 any time yeah my question is what kind of assessment would you have expected mr stokes to have made
00:45:20 have made um
00:45:24 there you can derive a very simple checklist i mean i think i've put it into both both of my reports yes um
00:45:36 and ask you can drive a very simple checklist and there's a so take the dual power supply
00:45:44 supply there's probably one drawing you need to check
00:45:47 check but to remember mr stokes had been told there was no there was no secondary power supply for that lift
00:45:58 that lift so even if he hadn't decided to assess it himself he was he he was told anyway
00:46:11 would it lie within the field of competence of a an otherwise reasonably competent fire risk assessor embarking on their task to undertake a review of compliance of any element of
00:46:22 review of compliance of any element of the building including in particular lifts for the purposes of the building regulations well they either you know depending on the year you you either
00:46:34 depending on the year you you either have some helpful information so you don't have to do too much work but in in the case of grenfell tower where how it had all the characteristics
00:46:46 where how it had all the characteristics of a fire lift i think
00:46:50 i think the the standards that explain fire lifts and the standards that explain firefighting lifts are helpful for you to like on even on
00:47:01 are helpful for you to like on even on the process of elimination notice
00:47:05 notice some of the features don't exist if you don't feel you're capable of doing that as a minimum you should write down i
00:47:16 as a minimum you should write down i don't know what type of lift is installed in this building someone competent needs to confirm that and therefore i'm not going to say it's safe to use use in the event of a
00:47:29 it's safe to use use in the event of a fire if if that's all you're capable of doing right thank you now if mr stokes had proceeded on the assumption just to just work on this hypothesis if mr stakes
00:47:42 work on this hypothesis if mr stakes was proceeding on the assumption that
00:47:46 the lifts of grenfell tower were firefighting lifts because they had been as he thought replaced in 2005 and therefore assumed that they were compliant with the building regulations
00:47:58 the building regulations would that have been a valid assumption
00:48:03 if you had made the assumption that the lifting in grenfell tower had been replaced in 2005 and therefore were firefighting lifts in order to be compliant would that be a valid assumption
00:48:15 just to make that assumption in an existing building yes
00:48:21 i i was involved i i don't think so i mean i think don't the facts kind of speak for themselves i mean it's a dangerous assumption to make it's a dangerous assumption yeah because you
00:48:33 assumption yeah because you my harsh experiences then turns out that you're wrong yeah you know so i think it's dangerous to make because because the the the fire lift is distinct from
00:48:45 the the the fire lift is distinct from the firefighting lift remember there's another thing they tend not to be able to do which is to return to ground in the event of a fire okay so
00:48:55 so i i for me anyway when it comes to to lifts i i do think you need to be careful because they can cause other issues in the event of a fire but i'm people might classify me as
00:49:07 fire but i'm people might classify me as cautious but i think you should know yes i think thank you and if the passenger lives at grenfell tower as a matter of fact we're not replaced but we're refurbished yeah yeah what then
00:49:19 it's the same well if if you've made it your business to discover they've only been refurbished and not replaced your confidence in them needs to be even lower even lower yeah
00:49:31 needs to be even lower even lower yeah right thank you very much now and then let's turn to the question of the testing of the firefighting switch um
00:49:40 i'm trying to cut a long story short here but but the fra pro forma produced by mr stokes um
00:49:47 um was amended so so as to provide the monthly testing which was suggested by the past 79 template became monthly inspection
00:49:59 template became monthly inspection yeah so instead of testing as recommended in past 79 he meant he emended that and put in inspection instead yes yeah concerning fire lifts
00:50:10 fire lifts in what ways would inspection differ from testing
00:50:15 he removes um so in my mind
00:50:21 as took place well so an in inspection requires a competent person in the lyft world as opposed you know if
00:50:33 in the lyft world as opposed you know if competent sorry that sounds a competent lift contractor there's a whole series of duties in the lift standards the testing of the
00:50:45 the testing of the the lift switch which
00:50:47 which is actually cited as weekly not monthly in modern standards is a relatively simple is a simpler task
00:51:01 so i can't do a lift inspection right i'm not quite allowed to do so i i can ask for a lift i'd prefer someone else to do the
00:51:12 a lift i'd prefer someone else to do the lift test because i've been stuck in lifts too often but i like to witness the lift test being done i i i'm not capable of doing a lift inspection
00:51:23 capable of doing a lift inspection you just you you i think you used the word test and inspection interchangeably when it's now oh that's probably because i do
00:51:31 i do so the test is of the the switch right the inspection is of the lift and all there's all different parts of it i see so okay the lift equipment to be fair to
00:51:43 so okay the lift equipment to be fair to mr stokes is it in fact the case that he strengthened the standard suggested by the past 10 79 template by upgrading the
00:51:52 the we the monthly um
00:51:54 um uh monthly testing to monthly inspection i don't know what mr stokes meant by inspection as distinct from test right okay because just to get a bit back to
00:52:05 okay because just to get a bit back to the relevance of gra at great for grenfell tower as i've sat out at length you know i i don't know that anyone tested
00:52:16 tested the the switch to the lift which is the main duty
00:52:21 main duty uh
00:52:22 uh in terms of uh for a fire risk assessment now can i show you what mr todd says in his main report about this topic it says that cta
00:52:30 that cta six zeroes eleven page eighty nine
00:52:42 and at paragraph eight point eighty one mr todd says i am unclear as to why mr stokes omitted any reference to weekly testing
00:52:51 testing weekly testing it might be that he considered this frequency of testing was somewhat impracticable and unnecessary in the case of a block of flats as opposed to a commercial building in which case i would agree with his view weekly testing is included in the past
00:53:03 weekly testing is included in the past 79 template simply because it's recommended in other standards um
00:53:09 um two questions i have for you dr lane on that if weekly testing of the lift override switch is recommended by other standards such as the lga guide and indeed by pass 79 itself
00:53:21 indeed by pass 79 itself um
00:53:22 um by inclusion in the template was the fact that mr stokes was assessing blocks of flats any reasonable basis for excluding it no and particularly because the british standard far left which gives the most
00:53:35 standard far left which gives the most coherent information the the most recent one says a weekly test
00:53:42 test and then an annual i'm going to use the word this is my word major inspection okay
00:53:48 okay the monthly inspection in the latest standard is actually about testing and the the monthly activity is actually about testing if the secondary power
00:54:00 about testing if the secondary power supply
00:54:01 supply the the lift can do what it needs to do in secondary power mode so
00:54:09 i'm not sure that i can agree the intention was to make things more robust by switching from weekly to monthly and do you agree at all with mr mr todd's
00:54:20 do you agree at all with mr mr todd's view that it's impracticable and unnecessary to test the override switch weekly in a block of flats as opposed to a commercial building no i don't i don't agree
00:54:31 i don't agree now in his oral evidence uh mr todd explained and this is a day 167 page 189 lines 8-13
00:54:42 167 page 189 lines 8-13 that it was his view that the british standard was quotes unduly onerous in asking for weekly testing quotes and merely increased the wear and tear on the switch would you agree with that no i wouldn't
00:54:54 would you agree with that no i wouldn't why not
00:54:58 why do i not agree okay so let can i just say a few things about that if if i was working in a building and the responsible person had
00:55:09 and the responsible person had routine inspection process that was being implemented robustly and it
00:55:18 and it they were doing the test of the switch every month and when i did my independent test everything worked perfectly
00:55:25 perfectly i wouldn't mark up the risk level on the grounds that well you know you're doing a great job monthly i wish it was weekly okay
00:55:36 it was weekly okay none of this applies to grandfather okay there's no evidence of of robust testing of the switch in my opinion i don't understand i i just you know mr
00:55:48 don't understand i i just you know mr todd has his views for all the reasons he has his views i'm probably just a little bit more boring in the sense that i read the lift standard very comfortable people have written it they say to test that
00:56:00 written it they say to test that particular switch weekly and i think it's for for very good reason now mr told also suggested that monthly testing of the firm and switch would be adequate and he considered
00:56:11 would be adequate and he considered monthly testing a much more pragmatic period
00:56:15 period that's day 167 page 189 lines 11 to 13. are we to take it from the evidence you've just given that you disagree with that no i think that's if it's being done which it was
00:56:27 that's if it's being done which it was not being done at grenfell you know we're not in some fine line in matters around grandfather that you know they were testing the switch monthly and i've been really critical because it wasn't weekly
00:56:39 because it wasn't weekly that's not relevant to grenfell i think it's weekly if i if the if i was working with a responsible person and they had a really consistent
00:56:50 consistent well-implemented program of testing monthly
00:56:54 monthly i wouldn't rank the risk level up so high and i wouldn't severely criticize them if it's being done properly which it was not a grandfather
00:57:08 but that would wouldn't that be a departure from the standard which requires weekly testing it would be a departure yes and if you know if
00:57:20 and if you know if a fire risk assessor is going to agree to a departure it has to be for inexplicable reason if you will right i think i don't want to
00:57:34 i think if someone's doing something very well consistently every month as distinct from every week i would be happy to contemplate the meaning of that that's not relevant to
00:57:46 meaning of that that's not relevant to grenfell tower mr todd's view the basis of his view and i'm summarizing is that the the switch isn't likely to fail week by week and there's no point sending somebody across london to test a switch
00:57:59 somebody across london to test a switch that is unlikely to fail and therefore simply as a matter of of
00:58:04 of period
00:58:05 period uh it was
00:58:07 uh it was adequate yeah uh and pragmatic to test the switch monthly yeah and not weekly would you agree with that just simply no i i i i
00:58:18 just simply no i i i i it does well fair how do how do you know when it's going to fail i mean that's the whole problem isn't that if i was going to agree to it monthly i what i'm doing is allowing an extra
00:58:29 i what i'm doing is allowing an extra three weeks where it may have failed that's the judgment i'm going to make so does it come to this that you disagree with mr todd on his uh on his explanation as to why monthly is okay
00:58:40 monthly is okay instead of weekly um
00:58:43 um but you would you you would you would go with monthly without raising the risk level provided you were satisfied that it was yeah there was a good reason to do so and the other measures were in place so i think mr as you're telling me
00:58:56 place so i think mr as you're telling me mr todd's
00:58:58 mr todd's explanation of monthly on the grounds it won't have failed i don't agree with right okay a responsible person having a great set of management procedures in place where
00:59:11 of management procedures in place where that test is you know without fail checked every month i would find it very you know i i would be wary about carr you know really criticizing them for that
00:59:23 criticizing them for that okay and i think that's very different to what mr todd has said but he needs to confirm that yeah can i then show you what he told us on day 167 a little bit late little bit further on about the
00:59:34 late little bit further on about the british standards this is day 167 page 190
00:59:38 190 uh at uh line 20
00:59:42 20 over to
00:59:43 over to page 191 line 7 at line 20 he's in the middle of an answer yeah and he says now your question will probably be sir
00:59:55 now your question will probably be sir well then why did you not say that in past 79 or the lga guide the answer is you're not allowed to write into one british standard something that conflicts with another british standard even if what the other british standard
01:00:06 even if what the other british standard says is stupid or that's unfair over the page julie unduly onerous so we had to write it into past 79 and if we'd written the lga guide and we'd said every month i'd be sitting here and
01:00:17 every month i'd be sitting here and you'd be saying who were you to change the british standard to every month but there's more of a recognition now so that testing things in blocks of flats every week is probably unreasonable
01:00:29 every week is probably unreasonable um
01:00:30 um question for you dr lane are you aware of any consensus or understanding within the fire safety industry up to june 2017 that the requirement for weekly tests of the lift firefighting
01:00:42 weekly tests of the lift firefighting switch
01:00:43 switch in sorry the fire fighting lift switch in blocks of flats was unreasonable no i'm not i mean yeah
01:00:51 yeah i think you know um
01:00:56 the relevant pressure standard there's a different reason for the weekly monthly
01:01:03 monthly and annual activities and i think they're for very good reason and i wouldn't understand why one would make them interchangeable and i you know that's mr todd's kind of
01:01:17 and i you know that's mr todd's kind of and given the requirement for weekly testing of the switch was included both in the lga guide which we haven't shown you and the past 79 guide which i have would you have expected a
01:01:29 which i have would you have expected a reasonably competent fire risk assessor to have recommended that the duty holder undertake weekly testing i would that he's checked that they're doing it yes not just say please do that the job
01:01:41 yes not just say please do that the job is to check that it's happening and that's why it's really important to do to observe it for yourself as well and is it your opinion based on what you've told us that uh the reasonably competent
01:01:52 told us that uh the reasonably competent fire risk assessor would only be free to recommend a frequency which differed from the published guidance or standard for good reasons yeah so if if you if in
01:02:03 for good reasons yeah so if if you if in in the in the case of mr stokes who had great access to
01:02:10 to the buildings because he was there for several years um
01:02:14 um every two years or every year you can witness the reliability of the fire risk management system that's delivering a tested lift switch
01:02:26 tested lift switch the only reason for it is so that it performs adequate you know performs the right way in the event of a fire so if that's consistent all the time i wouldn't get into a massive debate with
01:02:38 wouldn't get into a massive debate with anyone that is not what happened at grenfell tower and in your report we don't need to go to this part of it chapter 7 paragraph 7.8.78 page 82. it you you indicated
01:02:51 7.8.78 page 82. it you you indicated tell me if this is wrong that it would have been appropriate for a suitably trained member of the tmo staff
01:02:57 staff to have undertaken the weekly test of the operation of the fire lift switch yeah that's yeah yes now we've heard evidence from some of the estate um
01:03:08 um managers the esa's on that yes mr stedman paul stedman confirmed that they never tested the fire control switch in the lifts of grenfell tower at all that's correct yeah um
01:03:19 that's correct yeah um would you agree that the normal and accepted standards but the the normal standards required mr stakes to understand the routine inspections and tests on the lifts absolutely because it's it's
01:03:31 it's it's it's one of the outputs of a fire risk management system and you your risk level is wrong if you don't understand the qua you know
01:03:43 if you don't understand the qua you know the condition of the fire risk management system and the various procedures it's relying on and routine inspections are a really important manifestation
01:03:55 are a really important manifestation of
01:03:56 of a functioning fire risk management system and would it follow from that that the fire risk assessor should understand both who was undertaking those tests and inspections
01:04:08 undertaking those tests and inspections and the scope of those tests yes and to record those accurately in the fra yes can i then turn to the topic of flat entrance doors which is a completely new
01:04:20 entrance doors which is a completely new topic
01:04:21 topic uh mr chairman is terribly early for the break so i'm going to make some progress on it i think that would be better yeah uh now um
01:04:28 uh now um first of all can we look at this question of fd30 as against fd30s yeah um
01:04:35 yeah um is there a difference between a door and a door set when it comes to resistance to fire
01:04:49 [Laughter] the
01:04:52 the doors
01:04:54 doors the door the door set is there is it is the whole assembly and that's what's required to perform in a fire right um you laughed at my question
01:05:07 right um you laughed at my question some of these questions sound really simple but they're they're fiendish and it in this environment sometimes it's a bit oh yeah so sorry that's just me so it's the door set obviously i'm not
01:05:18 it's the door set obviously i'm not going to say to you why are you asking me about the two different things help me it sounded to me like an incoherent question because if i've understood the position correctly that's what i thought missed
01:05:27 missed the name
01:05:28 the name door set is a piece so to speak is yeah it all works as one exactly so the door set is the whole thing the door leaf is just
01:05:37 just kind of frantically looking around the moon
01:05:41 the moon yeah okay she said expert very good
01:05:46 um the chairman has characterized the questions you can hear it and i think i thought it sounded incoherent well they'd be able to sway me that it wasn't but if you could hear
01:05:57 me that it wasn't but if you could hear it
01:05:59 it uh
01:06:00 uh can you explain briefly the characteristics that are necessary for a door set yeah uh to be considered fd30 can i explain the characteristics
01:06:13 yes so they're so the the door set so the frame the leaf
01:06:21 leaf the door closer the door opener the latch or the glass if there's glass all
01:06:31 all the different components of the door together
01:06:36 together and
01:06:36 and sorry also depending on the manufacturer there will be intumescent seals around the leaf or on the frame and also behind some of the iron mongeri it depends on
01:06:48 some of the iron mongeri it depends on the manufacturer of the door so they are kind of well-known classic
01:06:57 elements of the door set that once that set has been tested should give fd30 and then to get the s there's an additional
01:07:09 there's an additional it's called a cold smoke seal and that's subject to a a cold smoke test
01:07:16 test you say that's subject to the cold smoke test um sorry i should have said sir excuse me the whole assembly with the the smoke seal is subject to the cold smoke test thank you yeah so
01:07:28 the cold smoke test thank you yeah so that's the key point i wanted to tease out is it the case that where uh
01:07:35 uh fd30s
01:07:37 fd30s doors are required to be installed you can't simply take an fd30 door fit cold smoke seals to the door or to the frame and then treat it as an fd30s
01:07:48 and then treat it as an fd30s door correct there's two tests needed and the
01:07:52 and the you don't need me today i mean did the door manufacturing industry are very clear there's lots of very helpful publications about the significance of that and is
01:08:03 about the significance of that and is this right to be to be um to meet the specifications of fd30s yes the door set has to be tested for ambient or cold smoke leakage in accordance with british
01:08:16 smoke leakage in accordance with british standard 476 part 31.1 yeah yes yes that's correct sorry trying to remember the british standard yes that's correct
01:08:26 now uh let's look at uh mr stokes uh can we go to st sorry cst four zeroes two six six zero
01:08:40 uh this is a letter sent by mr stakes to jan israel on the 10th of november 2010 subject the replacement of fire doors to some entrance doors of residential
01:08:51 to some entrance doors of residential flats and the title under that criteria for prioritizing the fitting of new entrance doors to flats and then at the foot of the page you set out some options three options in fact
01:09:02 out some options three options in fact in total
01:09:04 in total option one replace the old door and frame the door set with a new 30 minute fire rated door set incorporate oh sorry you're down at the bottom okay sorry excuse me
01:09:15 the bottom okay sorry excuse me yeah replace the old door and frame the door set with a new 30 minute fire fire-rated door set incorporating intumescent strips and cold smoke seals fd30s with a self-closing device yeah
01:09:26 fd30s with a self-closing device yeah then over the page two replace the old door with a new 30 minute fire rated door inserted in the old frame incorporating intumescent strips and cold smoke seals in the new door fd30s with a self-cleansing device
01:09:39 door fd30s with a self-cleansing device yeah
01:09:40 yeah three fit into mess and strips if not fitted and cold smoke seals in the existing door and a self-closing device to the door yeah those are the three options
01:09:49 options uh
01:09:50 uh did mr stokes correctly advise was he right that the specification of those replacement doors should be fc fd30s
01:10:00 fc fd30s so the overall performance yes should be fd30s if that's correct yes and which of these three options would deliver an fd30s door and just go back
01:10:11 deliver an fd30s door and just go back to the other page creating page one please option one
01:10:27 i feel slightly like i'm at an exam now but i think reading this english here replacing the door and frame with the new
01:10:37 new yeah no he's got he's got it there the the rated door and then the cold smoke seals ft-30s he doesn't say anything about testing but that could be the right option right
01:10:48 but that could be the right option right i see now can we then go to um cst 3013074
01:10:55 this is a letter written in march the next year 7th of march 2011. yeah updated a few days later on the 10th of march 2011 as you can see yeah after a meeting with simon throp
01:11:06 meeting with simon throp and
01:11:07 and uh he says uh three paragraphs on the man's master door limited company website it states that their doors quotes meet the requirements of part m
01:11:18 quotes meet the requirements of part m of the building regulations and fire check versions have also been successfully tested to bs 476 part 22 close quotes question one can it please be confirmed
01:11:30 question one can it please be confirmed that the doors that are to be fitted under the contract are the 30-minute fire doors fd30 yeah version and could the company forward all the relevant documentation to confirm this in the specifications and information
01:11:42 in the specifications and information there appears to be no mention of self-closing devices being fitted to the apartment entrance doors nor that the doors will have intumescent seals um
01:11:52 um should state mr stokes have asked for confirmation that the doors were fd 30s doors yes because that that's the performance well what yes he should have yes
01:12:03 well what yes he should have yes now if we go to page two in the last paragraph on that page you can see that mr stakes had received confirmation uh underneath his signature updated information after 10th march meeting
01:12:15 information after 10th march meeting with with jay ray and s throp simon confirmed that the replacement doors would have self-closures and cold smoke seals fitted to them also the letterboxes would be fire rated
01:12:26 letterboxes would be fire rated we've seen no evidence that mr stokes insisted that the door or door sets were certified fd30s or tested to that standard
01:12:34 standard uh following that confirmation and my question is would you have expected mr stokes to have raised that with the tmo uh
01:12:43 uh raised raised the fact that he'd seen no uh
01:12:47 uh evident no confirmation from mance masterdoor that the door sets had passed the relevant tests so as to make them fd30s yes because in this particular case for
01:13:00 yes because in this particular case for the people who haven't read all around this
01:13:04 this he had been asked for a specific view about the door performance well it wasn't within a fire risk assessment moment
01:13:13 moment he had been asked to give advice about the door so he did need to make that clear
01:13:20 clear and he did need to to check yes right thank you now can i show you what he said in his evidence um and the background to what i'm about to show you is that in may 2011
01:13:31 is that in may 2011 um he wrote to janice ray and referred to the doors being fitted as fd30 doors i don't think we need to look at the letter
01:13:39 letter um
01:13:40 um if i can show you the transcript of mr stakes's evidence at day 138 page 54. i'd like to pick it up at line 20.
01:13:54 and at line 20 the question is asked so after the trial door installation it seems that you provided your opinion on whether the door or doors complied with
01:14:05 whether the door or doors complied with the requirements of the fire safety order and approved document b yes correct
01:14:10 correct and you confirmed that they were fd30 yes
01:14:14 yes can we go with the page
01:14:18 91 answer from the information i was given yes
01:14:22 given yes question and that was contrary to your advice wasn't it of the requirements for the doors which you gave before the installation which was that at least according to the parts of adb that you highlighted in green there should be fd30s
01:14:33 fd30s i disagree the doors are fd30 and as it says in this document the so it says here the door fitted was an fd30 and then it says there's fitted reinforced frame the door
01:14:45 there's fitted reinforced frame the door was fitted with self-closing device intumescent and cosmic seals so therefore that makes it the s
01:14:53 so you're referring there are you to lower down the paragraph correct which is the paragraph we just looked at it doesn't say anything about fd30s in there does it you don't refer to that no but it says on there intumescent and cold smoke seals in the fire rated
01:15:05 cold smoke seals in the fire rated letterbox
01:15:07 letterbox now
01:15:09 now uh this is him explaining in effect why he considered um
01:15:13 um his notes that the door installed fd30 uh was not contrary to his earlier advice
01:15:20 advice uh
01:15:21 uh that the
01:15:22 that the the door needed to be an fd30s is his explanation correct well
01:15:28 well what document was that you and he were looking at we're looking at the last paragraph of the letter oh of his letter yes oh okay well then what was your question again well perhaps we should
01:15:39 question again well perhaps we should have it up at the uh no no it's okay i understand i thought maybe you were talking about the brochure or some of the other documents no no the the the confirmation letter the confirmation that mr
01:15:49 that mr stokes received from janet ray janice ray and mr simon throp yeah uh that the doors would have self-closures and cold smoke seals fitted to them yeah so that they they could have
01:16:02 so that they they could have been fd30s but he needed to know that they had the two tests done and that they were
01:16:09 they were right i'm going to say you know compliant or sold because they're sold test what they're meant to be sold as tested yeah can i we need to understand don't we the doors that are supplied are
01:16:20 don't we the doors that are supplied are not themselves individually tested they're made to a pattern that's been uh exactly they're made to a pattern and so
01:16:28 so the specific door has a specific pattern that has been proven through tests that that unique pattern works yes there's a prototype
01:16:40 yes there's a prototype yeah presumably yes yeah yeah i'm just going back then to the transcript in light of that that answer and and just to just to be completely clear
01:16:52 completely clear where he says at line seven the doors are fd30 and as it says in this document the door fitted fd30 then it says fitted reinforced frame the door was fitted
01:17:04 reinforced frame the door was fitted with self-closing device intumescent and cold smoke seals so therefore that makes it the s
01:17:11 it the s is mr stokes his explanation that the simple fitting with the self-cleansing device intimacy and cold smoke seals is what makes it the s and is his explanation
01:17:22 and is his explanation that by fitting the self-closer and the intumescent cold smoke seals to the the door in this pattern of doors yes it turns the door into an 30s
01:17:33 turns the door into an 30s one is that an explanation which a reasonably competent fire risk assessor might give they very well might but it would be wrong right so your point is that unless
01:17:44 wrong right so your point is that unless it's made to the pattern that's been tested yeah it's not a mess but he might have been a bit sloppy in his use of language here yeah exactly so the
01:17:53 the the the cold smoke seal one you know so the right cold smoke seal in the approved door should get you the s rating in the cold
01:18:05 should get you the s rating in the cold smoke test yeah okay the intumescent and the fire rated letterbox are all to do with getting the the baseline fd30
01:18:17 the baseline fd30 right the heat so that's to do with heat yes the cold smoke seal is a cold different test yes yeah but exactly and what i'm trying to drive at well regardless of the question of pattern
01:18:29 regardless of the question of pattern yes is is it right that you can take an
01:18:32 an fd30 door set put some cold smoke seals in it and then call it an fd30s no you can't and there's an obsession obsessive attention to detail
01:18:43 to detail in the door industry because of how quite it's it's difficult to without very careful design you know to well i probably
01:18:55 design you know to well i probably fd30 and fd30s require very specific detailing not any old thing i think is the best thing to say right and is that because in order to
01:19:06 because in order to supply in order to call a door set an fd30s the type of door set you're selling or supplying yes has to be tested to bs 476 part 31.1 yes thank
01:19:19 be tested to bs 476 part 31.1 yes thank you
01:19:20 you now uh towards the end of 2011 do you think we've got to a convenience oh we have yes mr germany i think you would have a break at this stage they will take the break we'll come back at 25 to
01:19:31 take the break we'll come back at 25 to 4 please yep again no discussion about your evidence no problem thank you very much
01:19:46 right 25 to four mr williams i think i've raised this with you before do we not have the paperwork for the supply of these doors which shows what was actually ordered
01:19:57 which shows what was actually ordered i've asked that question a number of times the answer is what we have is what is what has been seen we have no other paperwork
01:20:05 paperwork you know the documents at some point indeeds will be interested to see what paperwork we have well i'll come back to you after the break on with a i hope a chapter and verse answer thank you very much 25 to 4 please
01:38:01 would what ask dr elaine to come back in please thank you
01:38:16 all right dr lane ready to carry on yeah thank you very much yes now um thank you very much mr chairman towards the end of 2011 doctor dr elaine following the flat entrance doors installation program
01:38:29 doors installation program it appears that mr stokes became aware that some of the self-closing devices for some of the doors installed during the program were presenting problems and you cover this in your report at chapter eight
01:38:40 chapter eight and can we just look at that um can we go to blarp2
01:38:45 page 314.
01:38:51 uh you pick this up at paragraph 13.8.7
01:38:56 and you say that when mr stokes issued his 2012 fire risk assessment on 20th of november 2012 102 of the final total of 106 mans master
01:39:09 of the final total of 106 mans master doors had been installed in grenfell tower and you give a reference for that and then you go on to say 13.8.8 mr stokes made no reference to the recurring faulty identified with the
01:39:20 recurring faulty identified with the mans master door self-closers nor whether all of the main flat front entrance doors in grenfell tower had been remediated by a man's master door this was a serious omission as if at that time the self-closers were
01:39:32 that time the self-closers were non-functional it already posed a potential risk to life of the relevant persons and those pers those doors could not be relied upon to act as the collective protective measure except in some circumstances
01:39:44 some circumstances why do you think it was incumbent on mr stokes to have recorded in his fra the recurring faults he had identified with the man's master door doors because the fault that he
01:39:57 because the fault that he he became aware of meant the door wasn't offering the protection being relied upon in the building
01:40:11 and if we go on to page well go to blarp25040 page 70. let's look at what you say at that page
01:40:22 let's look at what you say at that page in chapter 11. paragraph
01:40:25 paragraph 22.3.39 you say first i have not been able to find any evidence that mr stokes uh nor any employee of kctmo ever investigated the performance of the
01:40:37 ever investigated the performance of the fire doors in grenfell tower to assure themselves they had indeed been repaired as mance mastador had originally claimed yep
01:40:45 yep and when you say investigate investigate the performance what what did you mean i i mean that if
01:40:53 if if you're aware of a fault with a protection measure that reduces or removes its performance you uh
01:41:02 you uh you know in the case of man's master door they they said they were they were going back to replace the faulty items i think that you need to go and check to make sure that has happened that's what i meant right
01:41:15 that's what i meant right and you say check do you mean check in the building or check with the tmo who the risk assessor yes well i think i think that a boat
01:41:24 a boat because the the repair works needed to be triggered by the t you know the repair works sorry needed to have been the tmo staff needed to know the repairs
01:41:36 the tmo staff needed to know the repairs that the contractor claimed to be making were being carried out and i think the risk assessor should have been sufficiently curious when he was the one actually who seems to have known he certainly knew before miss ray
01:41:49 known he certainly knew before miss ray when it came to his next risk assessment when he was inspecting some doors he should have satisfied himself that the repairs have been made the closers were working right and it was the timing
01:42:01 were working right and it was the timing for that when he did his next risk assessment yes or before that the timing of that do you mean should he have generally checked the door closers because it might be two years before he
01:42:12 because it might be two years before he did the risk assessment if he personally wasn't going to do that and it wasn't necessarily his job to go off and do an inspection outside his risk assessment he absolutely needed to
01:42:25 he absolutely needed to inform the kctmo of the urgency that any person checked if the faulty closers were being repaired so the door offered protection
01:42:40 so he had to warn or do something in this case i think it was to warn
01:42:53 and then when his time for his risk assessment came yes he needed to satisfy himself also so the two things and we're not doing any of those things that you've just referred to fall below the standards of the reasonably competent
01:43:05 standards of the reasonably competent fire risk assessment yes and and there are the standards expected of a responsible person whose responsibilities for a fire risk management system yes thank you
01:43:16 management system yes thank you now
01:43:17 now let's go then more centrally to the topic of checking doors during inspections during fra inspections can we can we go back please to blarp25027
01:43:29 and this time go to page 303 chapter 8
01:43:33 chapter 8 and look at paragraph 13.3.29
01:43:40 and it says here the lga guide is therefore clear that at least a sample and you've quoted it above at least a sample assessment of flat front entrance doors is required and the need to gain entry to those flats to undertake the assessment
01:43:53 flats to undertake the assessment um that now you have quoted it but to be clear let's look at what the lga guide says hom3045964 page 45
01:44:03 and i'd like to look at section 35 on that page
01:44:12 where we see type 1 and lower down type 2. type 1 common parts only non-destructive this is the kind of risk assessment that is identified type of risk assessment identified by
01:44:23 type of risk assessment identified by the lga guide and it says under type 1 in the second paragraph the inspection
01:44:34 in the second paragraph the inspection of the building is non-destructive but as well as considering the arrangements for means of escape and so forth the fire risk assessment includes examination of at least a sample of flat entrance doors you see
01:44:45 a sample of flat entrance doors you see that
01:44:47 that um
01:44:48 um i'd say when we see your opinion that i've just shown you at paragraph 13.3.29 was that the basis of your opinion to do a sample yes well
01:45:00 the basis of my opinion is also i suppose what i do right is that if that's fair to say yeah would you agree that the inspection uh of
01:45:10 uh of the sample of flat entrance doors would require the fire risk assessor to gain access to the relevant flats in order to in order to examine the presence of or the state of the door
01:45:21 the presence of or the state of the door closer
01:45:22 closer the door closer and other parts of the door that are important to offer protection i was going to ask you and cold smoke seals for example uh and the you know we talked about the intermediate strips there's there's
01:45:34 intermediate strips there's there's various protective measures around the the clothes cults make seals intumescent strips and the firebox the general condition if you want to say of the frame and the leaf in practice what
01:45:47 the frame and the leaf in practice what kind of percentage of flat entrance doors
01:45:50 doors was considered suitable and sufficient in the trade at the time to constitute a proper sample as contemplated by the lga yeah so i i don't know about a numeric percentage so
01:46:02 don't know about a numeric percentage so that you know that is agreed it's five it's agreed it's 10 anything more
01:46:08 more or less
01:46:09 or less so there's no number in in my opinion that's set out um
01:46:15 um and it is a decision that has to be made by the risk assessor normally as a function of the overall condition of the building or they're not you know their knowledge of various
01:46:26 you know their knowledge of various things about the building right i see so it's a building specific sample yeah i think based on judgment is it
01:46:36 yes i think that's the best way of describing it there's no golden rule as they call it about a sample number
01:46:44 number that absolutely guarantees it's the correct sample so yeah sorry politics yes
01:46:52 yes mr todd's evidence was that five percent was sufficient if all the doors were the same yeah
01:46:59 uh although he thought it was on the slim side but not unduly yeah so with that all right so i understand what that means so this is the thing about the condition of the building so
01:47:10 condition of the building so if you take the case of grenfell tower they had had a ma you know they'd a new set of doors installed one would hope they were to the right standards they might be in good
01:47:21 standards they might be in good condition you might decide to inspect one door per floor she said frantically thinking i think that i think mr todd's uh what did you say five percent or ten
01:47:33 uh what did you say five percent or ten percent five percent yeah i think that's six doors isn't it a grandfather six which is
01:47:38 which is is less than one per floor i think it's about one every three stories so that is on the slim side yeah
01:47:45 yeah and ex except where a flat entrance store is identified as deficient in some way yeah mr stakes doesn't record in his fras the specific doors that he checked nor the percentage of jaws doors
01:47:56 nor the percentage of jaws doors inspected on any given occasion we know that as a fact would that be normal is it normal is it normal is it normal not not to record in your fra the specific doors that you've
01:48:09 fra the specific doors that you've checked i think if you've gone to the trouble of inspecting a door the average competent person would write that down
01:48:22 yes and would you write down the percentage of doors inspected if you had inspected a sample
01:48:30 a sample okay um i i think if you've given a log of doors you you've inspected that's perfectly adequate i don't know if you need to go on and do a mathematical assessment and decide if that's an
01:48:41 assessment and decide if that's an acceptable sample but it's important to record where you've inspected um because the point about sampling
01:48:52 um because the point about sampling is if you've done your five percent and you're finding consistent failures you're sampling your your inspection need needs to go up or the responsible person now needs to
01:49:04 or the responsible person now needs to make other arrangements to start to inspect further that's my experience of sampling i think you agree that it would be um good practice for a reasonably
01:49:15 um good practice for a reasonably competent fire risk assessor to record which particular doors they had inspected as part of the sample absolutely would it be unreal would it be bad practice or unreasonable for the first assessor not to do so is it
01:49:28 first assessor not to do so is it unreasonable would it fall below the standards expected of the reasonably competent fire risk assessment yeah i think so because again the the location of faulty or defective fire
01:49:40 the location of faulty or defective fire doors
01:49:41 doors impacts the risk level to persons in in that area so it's important to know where they are what would or what should a competent fire risk assessor do if
01:49:52 assessor do if they tried to get access to flats to carry out their sample but could not access a sufficiently representative number phone the responsible person and come back the next day or make them come and help you right
01:50:08 would it be normal and acceptable for a fire risk assessor only to check and record in their fra those flat front doors where they had seen a defect such as a hole or a
01:50:20 seen a defect such as a hole or a non-compliant letterbox
01:50:24 i i think you should record both
01:50:28 both so
01:50:29 so i think you should record both because you're building up a picture of the overall condition of an important protective measure in the building when you say both what do you sorry you
01:50:40 when you say both what do you sorry you said was a defective only so i think you should record all doors you've inspected whether or not you found defects or not you can make clear the
01:50:51 you can make clear the the flat entrance doors on level 11 were
01:50:56 in really good condition but for some reason the flat entrance doors at level 8 or in a different condition because there's a trend emerging there that needs further investigation would it be normal and acceptable for a fire risk
01:51:08 normal and acceptable for a fire risk assessor only to look at doors where there was an evident a manifest problem with it yeah so that that's that's normally a reasonable starting position right okay
01:51:19 reasonable starting position right okay but not the totality no would it be normal and acceptable for a fire risk assessor uh never to identify any problems with flat entrance doors which would only be apparent from an internal inspection
01:51:31 internal inspection can you just say that again yes would it be would it be acceptable would it be reasonable for a fire risk assessor not to identify any problems with flat
01:51:42 not to identify any problems with flat entrance doors which could only be apparent from an internal inspection
01:51:53 we've tried a different way yeah can you sorry i'm just getting a bit confused um if a fire risk assessor uh was going around a building trying to do his sample yeah would it be normal practice or except
01:52:04 would it be normal practice or except would it be reasonably acceptable practice for them to ignore any doors which didn't have a sign of any damage on the outside even though in fact the door closes may not work
01:52:14 work from an internal inspection yeah okay i see what you mean so the the fault is hidden and they assume because they've stood on the outside only yes is that reasonable way to start no
01:52:26 is that reasonable way to start no because you're you're so you start with a small sample and then if you're going to have to build up to something extensive as a function of what you've seen if you only ever stand outside the fire
01:52:39 if you only ever stand outside the fire door and make a judgment on harm potential on that basis you can't do that without looking on
01:52:48 on all around the door you can't see the protective measures fully from the lobby does that tell us that the the reasonably competent virus assessor would or certainly should as part of
01:52:59 would or certainly should as part of their sample look inside the door and look inside the door leaf to check um the efficacy of the protection measures even if there's no sign of apparent damage to the dog they should
01:53:12 apparent damage to the dog they should yes because it can be hidden it's it's a hidden feature of that protection measure now turning to the doors which mr stakes identified as presenting a risk or a hazard in his significant findings and action plans can be i'll
01:53:24 findings and action plans can be i'll show you three of those first of all the november 2012 fra action plan cst 403083 at page three item 12b
01:53:39 uh hi
01:53:41 hi there are holes in flat entrance doors of flats numbered 166 and 202. in number 166's case this is where a lock has been removed from the door these are original doors and they are
01:53:52 these are original doors and they are now not 30 minute fire rated doors i would recommend that these two flat central stores are repaired and replaced or replaced so that they are 30 minute fire rated doors fitted with self-closing devices complying with all
01:54:03 self-closing devices complying with all the requirements of the building regulations and then the next one at cst four zero three zero six nine page four this is june 2016
01:54:14 page four this is june 2016 his um action plan at page four item 12 g if you can just blow that up a bit more for to the page the flat entrance store of flat 24 is damaged with the letterbox
01:54:25 of flat 24 is damaged with the letterbox missing and then you can see the recommended actions to be taken there and then cst four zeros three zero six nine page five so the next page in this document
01:54:37 next page in this document 12 item 12h high priority the flat entrance door of flat 112 is being replaced this new door is not marked as a fire rated door and does not have a self-closing device fitted to it cold smoke seals are fitted
01:54:52 uh
01:54:55 that's 12 h and and you can see the uh the recommendations for that now if we could look at your report in the light of that can we please go to blarp 250 27 page 304
01:55:08 blarp 250 27 page 304 and let's look at paragraph 13.3.35 in chapter eight you say there mr stokes
01:55:19 uh therefore under mr stakes therefore undertook an examination of a sample of flat entrance doors apparently in accordance with the minimum requirements of the lga guide having heard the evidence of mr stokes
01:55:31 having heard the evidence of mr stokes am i showing you the documents in his action plans i've just shown you is it still your view that mr stakes undertook an examination of a sample of flat entrance doors uh
01:55:42 of a sample of flat entrance doors uh apparently in accordance with the minimum requirements of the lga guide i think do you mean because based on i think there's three or four doors there you fit through that very
01:55:54 doors there you fit through that very quickly
01:55:56 quickly are you asking me on the basis of the limited number of doors he recorded in those risk assessments do i consider that to be a sample is that what you mean yes that's another
01:56:07 is that what you mean yes that's another one it's a very small sample is it is it a suitable and sufficient okay so that's a very different question and the answer is no right thank you
01:56:18 is no right thank you if you've got roughly i'm not sure precisely 120 flat 120 front doors yes the 10 sample isn't very many any any of it is it's only 12 doors yeah exactly so probably
01:56:31 doors yeah exactly so probably just so what i would i start with is i do the stair you what we do is you do the stair door on one door you you might start with the stair one stair door one flat entrance door
01:56:44 stair door one flat entrance door but you have to be very mindful of the conditions around you and you may very quickly decide that that is not sufficient okay so if you do one door per in
01:56:55 okay so if you do one door per in grenfell tower starting at the ground you're up at 24 you're if you do ground up i know there's no flats down there there were no flats of ground you're very quickly at 24 doors
01:57:08 at 24 doors it's not time consuming to inspect a door either yeah
01:57:12 yeah so this is the danger of a you know a numeric sample it's it's yeah anyway sorry yeah yes
01:57:22 yeah and i think this comes back is this right it comes back to your answer earlier the the the size of sample yeah must is a matter of judgment based on what you know about the building yeah
01:57:33 what you know about the building yeah yeah it is and the layout of the building you know the number of doors the conditions in the lobby your understanding of the fire risk management system are you confident routine inspections
01:57:44 are you confident routine inspections are occurring so there's a lot of different factors that allow you to decide
01:57:50 decide there's a consistency in a building or there is lots of inconsistencies and so you need to increase your sample to satisfy yourself
01:58:01 increase your sample to satisfy yourself that you're making the right assessment of risk to the relevant persons
01:58:09 yes okay yes yeah now can we look at your
01:58:12 your report
01:58:13 report uh at page 321 within this same section chapter eight and look at paragraph 13.12.13. yeah
01:58:22 yeah you say there as a result yeah
01:58:26 yeah perhaps i should show you the previous paragraph
01:58:28 paragraph in neither of his april 2016 and june 2016 fire risk assessment yeah did mr stakes record significant findings relating to the disconnection of self-closers nor the non-compliant doors to the protected stair and the evidence
01:58:40 to the protected stair and the evidence shows he knew of substantial problems with the fire doors at grenfell tower as i've explained above as a result mr stokes made no assessment of the impact of any of the known deficiencies in these collective protective measures on
01:58:51 these collective protective measures on the safety of relevant persons
01:58:56 this may be a rather broad question but what was it that required mr stokes to make such an assessment well i i mean he was in a position of of great knowledge that some of us mightn't be in on first
01:59:08 that some of us mightn't be in on first arrival you know he knew there are problems with the stair door that's all dealt with in my report he knew for example the self-closers were being had been removed by different parties
01:59:20 had been removed by different parties so
01:59:21 so the consequence of that reduction in protection level
01:59:28 level the whole point of a risk assessment is you factor in that reduction in protection and it it it impacts your final risk level unless you're
01:59:40 unless you're providing temporary control or um or you're
01:59:46 you're you're agreeing a time frame for it to be repaired so the more defective flat entrance doors and stair doors there are the less internal compartmentation
01:59:59 the less internal compartmentation is provided to the relevant persons and was mis in your opinion was mr stakes required to factor in to his overall risk assessment for grenfell tower uh his his
02:00:13 grenfell tower uh his his uh findings that he had made or seen in relation to the disconnection of self-closures and non-compliant doors to the protected stair yes that's that's exactly the activity of of a fire risk assessor
02:00:25 activity of of a fire risk assessor doing a risk assessment would fail to do fair and would failure to do so full below the stand uh fall below the standards of the reasonably competent fire risk assessor yes in my opinion
02:00:37 yes in my opinion can we then talk about maintenance of flat entrance doors and self-closing devices can we start with chapter 4 of your report blarp 25030 page 45
02:00:48 25030 page 45 and i want to go to paragraph 4.2.1 in there please
02:00:57 you say there based and this is under the heading guidance on the scope and frequency of routine inspections based on my assessment of the guidance documents there is a degree of variation in the recommended frequency of routine
02:01:09 in the recommended frequency of routine inspections although all guidance documents are clear on the need to check the self-cleaning function of the fire doors
02:01:16 doors would you agree with this proposition that after july 2011 when the lga guidance was published a re a responsible person yeah was required to carry out inspections of
02:01:28 required to carry out inspections of flat entrance doors in accordance with the requirements of paragraphs 82.3 and 82.4 of the lga guide and i'll show you those if we need to yeah um
02:01:39 yeah um i'm probably struggling with the word requirement
02:01:44 leaving that question differently yeah would you expect a responsible person to carry out inspections of flat entrance doors in accordance with the guidance contained in those paragraphs because i think
02:01:57 in those paragraphs because i think the lga guide is actually particularly clear about self-closures and from memory
02:02:05 memory they're one of the few things that are associated with the word priority yes and you you recall i think that the lga guide recommends inspections of
02:02:16 lga guide recommends inspections of self-closing devices on doors on a six monthly basis yes yeah yeah um can you help what would count as a good reason for a responsible person not doing
02:02:29 for a responsible person not doing six monthly inspections of flat entrance doors good reason not to
02:02:37 no i i can't think of a good reason not to do that
02:02:42 do that can we sorry can we just make it what am i
02:02:45 i yeah um i think mr millet's asking you to consider that on the basis that every flat front door will be checked by being opened and
02:02:56 opened and allowed to close under its own power is that right well yes we we need to look at the
02:03:02 at the maybe better if if there's a confusion we look at the um i tell you remember we can in a minute but but yeah if that is what's being suggested yeah uh it might be said by for example the
02:03:13 uh it might be said by for example the tmo that to check in that way every front door of every flat in 650 buildings exactly every six
02:03:24 in 650 buildings exactly every six months would be disproportionately heavy on manpower time exactly so at the so i if i can speak in a theoretical sense
02:03:35 a theoretical sense if i was working with a responsible person and they were doing you know a marvelous set of checks every 12 months and you found during your risk
02:03:47 and you found during your risk assessment you know
02:03:50 you know functioning fire doors consistently it's you're back to that judgment again you're you're going to think very carefully about what that means their fire risk management system
02:04:01 fire risk management system is delivering performing fire doors though they're only doing an inspection every 12 months okay
02:04:11 okay that's substantially better than doing nothing
02:04:15 nothing or failing to achieve an unrealistic six monthly goal so it's about the outcomes and being careful of the outcomes is that okay i don't want people will say i've declared a new rule for frequency
02:04:27 i've declared a new rule for frequency and that's not what i'm trying to do um it sounds to me as though you would well tell me whether you would accept the proposition that the extent of your inspections
02:04:40 extent of your inspections may have to be tailored to the uh cost of carrying them out and the burden of um
02:04:50 um how frequently you get the burden of implementation and yeah you're always going to have some sorry whatever the nature of the system yeah there is always going to be a risk that some will not be functioning
02:05:02 that some will not be functioning because they'll slip through the net exactly and i think so again
02:05:09 so again now you're back again to let's say the overall condition of the particular building stock or the particular buildings in that stock okay um so if there are new doors
02:05:22 um so if there are new doors an annual inspection with a bit of a spot check but if you're aware of a property where the doors are so fundamentally let's say not acceptable that that's
02:05:34 let's say not acceptable that that's that's a different matter again okay so all the time there's a judgment required as a function of the risk to the relevant persons and your fire risk management system and
02:05:47 and your fire risk management system and your fire risk assessor you're working in that kind of integrated loop all the time
02:05:53 time okay thank you can i just then pause that a little bit if we can can we look at hom 3045964
02:06:04 look at hom 3045964 and look at page one two five which is where we find paragraphs 82.3 and 82.4 of the lga guide
02:06:19 because it is here that we find the guidance on inspection yeah under paragraph or section 82 and under fire resisting doors at 82.3 it says good practice is to inspect
02:06:31 82.3 it says good practice is to inspect timber fire resisting door sets on a six monthly basis as part of a program of planned preventive maintenance these inspections are aimed at identifying defects such as and then the first
02:06:42 defects such as and then the first bullet point is missing or ineffective self-closing devices and then underneath that at 82.4 flat entrance doors should be included within this program and then there's something about
02:06:53 and then there's something about leasehold flats which we didn't look at necessarily for this purpose so it's clearly recommending inspections on a six monthly yes basis as good practice yes my my question what was
02:07:07 practice yes my my question what was um what would count as a good reason for a responsible person uh not doing six monthly inspections in other words departing
02:07:15 departing from
02:07:16 from the six monthly periodicity yeah i i think
02:07:20 think you know i think i've answered that question now and we've had that discussion about overall condition of the building overall quality
02:07:28 quality of
02:07:30 of aspects of the fire risk management system would it be a good reason not to do six monthly checks that you didn't have the resources to do
02:07:41 that you didn't have the resources to do so across your estate if you didn't have the resources
02:07:51 if you don't have the resources to
02:07:55 to check
02:07:56 check the fire doors you you can't factor them in as robustly into the risk assessment as one might if one was able to carry out the checks
02:08:09 one was able to carry out the checks needed
02:08:10 needed so by
02:08:12 so by by making that decision based on resource
02:08:16 resource you're you're you're back to expat you know you're you're moving the goal post or whatever you want to say you're you're now increasing uh the potential for harm to relevant
02:08:28 uh the potential for harm to relevant persons and you have to balance that maybe with other control measures in the building well i mean would it be reasonable for a responsible person to say
02:08:39 say i'm not going to do six monthly inspections because i haven't got the money and i haven't got the manpower i'm only going to do them annually as i've already said if they're doing a thorough job annually
02:08:54 if they're doing a thorough job annually and the consistency in protection is being delivered that way i i wouldn't criticize that strongly but can i just say
02:09:07 i don't know how to phrase this some measures are so important you have to find the resource and the money don't you otherwise you have to start to think
02:09:18 otherwise you have to start to think it's like layers of an onion you have to start to understand the consequences of that
02:09:23 that and i all my buildings are stay put but i can't afford to look at the fire doors or check the compartmentation so there are consequences to all these
02:09:34 so there are consequences to all these decisions
02:09:35 decisions and they all have to be added together at the end to give a risk ranking for that building and you say some measures are so important you have to find the resources in the money were
02:09:47 find the resources in the money were self-closing devices to flat front doors yeah at grenfell tower yeah measures of the importance that you had to find the resource and the money
02:09:59 to find the resource and the money i think that self-closers are widely acknowledged as being highly significant in high-rise residential buildings
02:10:13 because of the high degree of compartmentation that is essential to the staple strategy so is that a yes self-closing devices are one of those yes life sometimes isn't simple enough
02:10:25 yes life sometimes isn't simple enough where i can just say yes here like sometimes i would love to say yes and i can't say yes okay but you you you might decide i can't afford
02:10:36 afford to repair all my broken self-closers so actually i'm going to have to change the evacuation strategy for my building i see thank you now looking at the question of inspections
02:10:48 looking at the question of inspections without regard to the period uh would would it count well would there be any good reason for a responsible person to do no regular inspections of door
02:11:00 to do no regular inspections of door closers no thank you
02:11:02 thank you now
02:11:04 now if we go to your report blarp
02:11:09 5 0 30 page 47 chapter 4. we look at to paragraph 4.2.8 and 4.2.9
02:11:21 just show you what you say there you say the self-closing device is a critical component of the fire door in order to maintain compartmentation in support of a stapled strategy by safeguarding the
02:11:32 a stapled strategy by safeguarding the means of escape regular inspection on the self-closing devices are therefore important especially since they are prone to wear and tear on flat entrance doors and doors leading to the stairs due to their
02:11:44 doors leading to the stairs due to their location on the main circulation routes my question is a simple one who would you expect to be carrying out the regular inspections
02:11:55 the responsible person and
02:11:58 and when you
02:12:01 look at the fire risk assessor's role yeah in the context of inspection and maintenance of flat entrance doors and self-cleaning devices in particular yeah do you agree that the role of the fire risk assessor
02:12:13 that the role of the fire risk assessor is to monitor and to assess the physical state of the repair of the doors and the door sets including this self-closing devices
02:12:21 devices and the adequacy of the system of maintenance and then
02:12:26 and then use those findings to determine the level of risk yes yes thank you would you agree that the inspections of flat entrance stores undertaken by a fire risk assessor as part of their fire risk assessment
02:12:38 risk assessment should not be a component of the maintenance and inspection system implemented by the responsible person that's an interesting actually that's a really interesting question yes if by agreement
02:12:49 yes if by agreement or or else no so there has to be clarity on i'm just aware um
02:13:00 sometimes a risk assessor is asked to do a very thorough inspection of every single fire door for me for maintenance purposes
02:13:09 purposes but it's not a matter of course and it's not implicit in the risk assessment process no thank you so yeah thank you so to put it another way you
02:13:20 thank you so to put it another way you agree that normally he's there to assess the duty holders inspection regime and not to provide it exactly yeah now
02:13:29 now the evidence of janice ray was that the tmo did not implement a six monthly system of inspection
02:13:37 uh of the flat entrance stores as recommended by the lga guide largely because of what she called resources and difficulties with access
02:13:48 it is the failure to implement the recommended program of inspection of flat entrance doors as per the guidance we've looked at a matter that you would expect a reasonably competent fire risk assessor to have identified during the
02:14:01 assessor to have identified during the course of their fire risk assessment yes uh and if this if is the evidence if if mr stokes didn't identify that as a failure on the part of the tmo in any
02:14:12 a failure on the part of the tmo in any of his fire risk assessments did that emission affect the suitability and sufficiency of his fras at least the grenfell tower yes
02:14:22 yes yes if if he didn't exp he didn't explain that it elevates the risk
02:14:30 risk did he anywhere no never now i've asked you some questions about um
02:14:36 um clause 20 of past 79 earlier on yeah and the fact that work recommended in the original um a plan of action not being completed needs to be identified we covered that
02:14:47 needs to be identified we covered that at some length and
02:14:51 and we saw clause 20 on page 61 there's no need to go to it which says work that has not been completed needs to be identified yeah can i just examine with you some of some specific instances yeah
02:15:03 you some of some specific instances yeah where mr stokes of mr stakes is actual knowledge of the condition of flat entrance doors
02:15:10 let me give you three specific examples try and keep them in your head and i'll take them slowly
02:15:16 slowly first july 2015 mr stokes is told that the self-closing device to flat 45 is missing yeah in december 2015 he raises a concern with janice ray that residents
02:15:29 a concern with janice ray that residents of grenfell tower had told him that one of the caretakers had disconnected a number of yes self-closing devices yes and thirdly mr stakes did not include that information in the next fra april
02:15:40 that information in the next fra april 2016 nor confirmed that the issues have been rectified in the interim yeah now working on that assumed fact pattern became with you um you make a comment in
02:15:51 became with you um you make a comment in your report at chapter 11. i'll show it to you
02:15:55 to you blarp25040 page 71 paragraph 22.3.45
02:16:05 can you say this i've not been able to find any evidence that mr stokes or any employee of the kctma ever investigated the performance of the fire doors in grenfell tower to assure themselves that self-closures
02:16:17 assure themselves that self-closures removed by mr dunlee had then been replaced
02:16:21 replaced and then if you go to um the next paragraph yeah uh i'm sorry the next paragraph for 1 47 mr stokes did not record the issues
02:16:32 47 mr stokes did not record the issues that arose between fire risk assessment visits to grenfell tower but more substantially he did not attempt to confirm if the fire door self-closure issue had been resolved either before finalizing his assessment of the risk level for grenfell tower
02:16:45 level for grenfell tower shown you both of those can you explain why you think that carl stokes should have recorded the issues that arose between his visits in his fire risk assessments because they impact the
02:16:56 impact the harm potential to the relevant persons and does that explain why you think he should have attempted to confirm if the self-closer issues had been resolved by the time of his next fra yes
02:17:08 the time of his next fra yes is it your opinion that he should specifically have checked those flat entrance stores that have been identified as deficient at least when he came to do his next fra yeah i mean first he should have been able to have
02:17:21 first he should have been able to have been briefed by the responsible person the situation had been closed out without him and then second he he he needed to do certainly start with the limited
02:17:33 certainly start with the limited independent check of some of the doors he was aware had not been functioning would a reasonably competent fire risk assessor proceed on an assumption that
02:17:44 assessor proceed on an assumption that if he had been that if he told his client the responsible person that a self-closer was defective it would be speedily fixed and he need to concern himself no more with it
02:17:56 with it the only way only if there was other evidence that things were being speedily fixed and the responsible person had such a fire risk management system right
02:18:08 risk management system right i've not seen such evidence when it comes to grandfather thank you that was my next question thank you very much now um mr stokes explained that he didn't include the information about the condition of the flat entrance door to
02:18:19 condition of the flat entrance door to flat 45
02:18:20 flat 45 grenfell tower in his april 2016 fra because it wasn't part of the fra but part of ad hoc advice to the tmo that's what he told us at dave 138 page 126.
02:18:32 what he told us at dave 138 page 126. yeah no lines 18 to 21. um would you endorse that approach no i wouldn't at all can you explain why not because i mean it's a piece of
02:18:43 it's a piece of information the risk assessor has um
02:18:47 um valuable information and it needs to be dealt with in the risk assessment again whether it's given ad hockey or not yeah so you would have expected mr stokes to record in his april 2016 fra his
02:18:59 record in his april 2016 fra his knowledge that self-closing devices had been removed or were missing since his last fra on october 24th yeah and that he checked again that day and they were still gone yes yeah thank you um now i want to turn to the next topic
02:19:11 um now i want to turn to the next topic which is the aov system when i say aov system i mean the system which was in place at grenfell tower before or up to 2016. yeah and not the
02:19:23 before or up to 2016. yeah and not the new system which is the subject of separate evidence and separate
02:19:28 separate evidence from you which i'm not going to go into
02:19:31 go into um
02:19:33 um uh there's ten minutes left on the clock mr chairman if we can make a start on this topic that would be helpful you have to keep going for ten minutes we've got plenty we're doing very well so we could break at this point yeah i'm
02:19:44 so we could break at this point yeah i'm in you know i allowed to say would be great to start but i don't want to sound rude around things am i allowed to say that would be great to start but i don't want to sound rude yeah and just check this out if we stop now are we safe to finish
02:19:57 out if we stop now are we safe to finish within tomorrow very safe very safe well in that case i think we can grant you an indulgence right we will stop at that point
02:20:05 point uh we'll resume please at 10 o'clock tomorrow that's fine thank you again no talking don't worry yeah all right thank you very much
02:20:18 no thank you mr miller i just thought it right just to check that we weren't going to find ourselves in an embarrassing position tomorrow afternoon no absolutely not well hence the rather tentative invitation well it was
02:20:29 rather tentative invitation well it was unusual i agree good
02:20:32 good thank you very much right well well that we shall uh stop there for the day and resume at ten o'clock tomorrow thank you very much
02:20:53 you