Evidence from Janice Wray (TMO Head of Health & Safety) about repeated failures of the automatic opening vent (AOV) smoke extraction system. Reveals system leaked smoke into multiple floors, was condemned as non-compliant in 2011, yet remained unfixed until after 2014 fire safety notice.
00:00:38 good morning everyone welcome to today's hearing
00:00:41 hearing today we're going to hear further evidence from miss janice ray say would you ask ms ray to come back in
00:00:56 please good morning it's ray good morning um i hope you're ready to continue yes good thank you very much yes mr miller yes mr chairman good morning mr
00:01:07 miller yes mr chairman good morning mr chairman good morning members of the panel miss ray good morning to you good morning
00:01:11 morning i'm going to start with a new topic this morning the aov system and within that topic start in turn
00:01:18 turn with the exist system as it existed before the refurbishment and within that the
00:01:25 the fire at grenfell tower in 2010 can i ask you please to go to your first witness statement at page 43.
00:01:57 and on page 43 please go to paragraph 195
00:02:01 195 under the heading grenfell tower fire in 2010 in april 2010 a fire broke out at grenfell tower as a result of someone setting fire to recycling stroke rubbish which had been left in a lift lobby for collection the lfb
00:02:12 lift lobby for collection the lfb attended and extinguished this fire and nobody was injured and then paragraph 202 if you go to page 44 you pick up the theme and you say there
00:02:28 uh i think we need to don't know mr williams i'm sorry i'm going to interrupt you for a moment my transcript is endlessly recycling
00:02:42 and i wonder whether other people are suffering from the same defect yes my colleagues are i i've got yes mine is as well ah now it's stopped
00:02:53 mine is as well ah now it's stopped but that's the but not on today's well i i keep rolling down the i keep writing down uh day 144 in draft which is not enough
00:03:05 uh day 144 in draft which is not enough i am now
00:03:05 i am now connecting i thought i'd solve it i'm connecting again to real time but actually
00:03:12 actually it's simply scrolling and i think anyone who's trying to make use of the transition as well that's going to find this impossible i agree and perhaps we should have a brief pause while we sort it out
00:03:24 brief pause while we sort it out i think it would be better i'm sorry miss ray we're going to stop as soon as we started always but i think we need to get the technology yes uh sorted out before we carry on all right and we'll call you back as
00:03:35 all right and we'll call you back as soon as we can okay thanks so much
00:03:43 this has gone wrong again
00:03:48 well having said that um i can only speak for my transcript but um
00:03:56 um it seems to have solved the problem should we just take a minute just to make absolutely sure or should we should we continue mr chairman let me just check that my colleagues
00:04:07 colleagues yours working yourself i was working on it right can i ask you to check with the council sitting behind you whether that's all working working working where are we
00:04:18 working where are we um i think the remoter access may not be working ah
00:04:27 yours is not behaving itself if you refresh it try refreshing it if you try refreshing it and see what happens we'll press real time again
00:04:39 this is all going on to the transcript
00:04:49 all right we'll raise for a couple of minutes to see if we can get very good thank you very much
00:15:15 welcome back everyone i understand that the technical problem has been solved and we're ready to continue with israel's evidence so would you ask ms ray to come back in please
00:15:32 [Music] mr i'm sorry for the interruption that i gather the technical problem has been solved and we're ready to continue okay thank you yes mr miller mr chairman thank you ms ray can i now ask you
00:15:44 thank you ms ray can i now ask you please to be shown page 44 of your first witness statement paragraph 202
00:15:50 this is the subject of the 2010 fire grenfell tower and you say we did investigate this fire internally and the information collated was sent to colette o'hara of the lfb we then provided mr awaderu with the
00:16:02 we then provided mr awaderu with the information we had on the fire in a letter from our project manager paul dunkerton
00:16:06 dunkerton in response to his email in november 2012 and you exhibit that now if we go to your third witness statement please tm00847305 page 36 let's pick it up at paragraph
00:16:20 page 36 let's pick it up at paragraph 120.
00:16:22 120. you say there that uh in summary uh in 2010 you collated information about the fire in an email you sent to coletto horror on the 5th of may 2010
00:16:34 on the 5th of may 2010 let's look at that that's a tmo one double zero four eight two two one at page four
00:16:44 this is the email uh and uh you can see it's fifth of may 2010 to colette o'hara copied
00:16:51 copied to among others robert black and lornette pemberton and sasha jevons subject fire at grenfell tower friday 30th of april colette further to our telephone conversations yesterday
00:17:02 our telephone conversations yesterday about this fire i would advise as follows and then you can see if you just scroll down a number of paragraphs uh over which go over the page was this effectively your written report
00:17:13 was this effectively your written report to the lfb concerning that fire yes it was and if we go to the second paragraph mark two on page one you see that it says the communal file detection system is linked
00:17:24 communal file detection system is linked to an extraction system and this did operate removing the smoke from the lift lobby unfortunately it appears that there was spillage straight leakage of smoke from the extraction system into the lobbies of floors
00:17:34 of floors 7 12 13 15 17 18 19 and 20. and this led to a number of residents to believe that their lift lobby was smoke logged and they were trapped in their home
00:17:43 home and as such they telephoned the fb raising their concern uh did you did you share that information with carl stokes
00:17:53 um i'm actually not sure that i did i'm i find it hard to believe that i wouldn't have but i don't think i can i can give you a definite answer at that stage um i think we just
00:18:05 at that stage um i think we just completed the high risk program and we were about to tender for the medium risk so i don't think we actually had an assessor engaged at that time i would have thought that when i appointed him i
00:18:17 have thought that when i appointed him i would have given him copies of correspondence all relevant correspondence any deficiency notices etc
00:18:22 etc but i can't be absolutely sure that i did well mr stokes is pretty sure that you didn't uh his evidence on day 139 at page
00:18:30 page six and at page seven was that he was aware that there was an arson incident in july
00:18:34 in july 2010 caused by bags of rubbish being left outside a flat door but didn't know about smoke spillage or leakage uh of smoke from the aov
00:18:43 aov on the lobbies of the floors you record in your email to colette o'hara here can you account for that um no and i would have thought the fact that he knows that detail it seems unlikely that he wouldn't have
00:18:54 it seems unlikely that he wouldn't have known all of this there was no there was no reason not to show it if i didn't show it it was definitely an oversight but i i just can't remember at this stage no well we don't have a record of you
00:19:02 you sharing it uh can we assume given your propensity to share things by email that you would have sent him an email had you shared it with him it's likely i would yes yes so um can we then go back to page 44 of your first
00:19:14 then go back to page 44 of your first witness statement please paragraph 201 we were we're on 202. i just want to look at 201 the previous paragraph
00:19:25 and you say
00:19:31 page 44 paragraph 201 foot of the page you say
00:19:37 you say halfway through the paragraph my understanding is that we never received such a report from the lfb and one does not exist i'm aware that it's possible to request a fire investigation report from the lfb
00:19:48 investigation report from the lfb following an incident however these reports are often delayed and provide limited information due to them being standard format and heavily redacted i've learned through experience that more comprehensive information can generally be obtained
00:19:59 information can generally be obtained through email requests to the relevant lfb station manager now can we look then in light of that evidence
00:20:06 evidence to a report this is iws 401463
00:20:19 uh it's headed report of the attendance of london fire brigade to a primary fire incident date of report this 22nd
00:20:27 this 22nd december 2010
00:20:31 and you can see if you scroll down you'll
00:20:34 you'll look down your screen the the fire ground
00:20:37 ground was north ken and the uh address was grenfell tower building name number grenfell tower did you see that yes towards the bottom of your screen do you recognize this
00:20:48 of your screen do you recognize this document
00:20:48 document um no i i think i became aware in preparing to to come to to give evidence that this existed but i don't think i've ever received a copy and that may be because i
00:21:00 and that may be because i didn't apply for one it most likely is that i omitted to to apply for one because we'd had such extended um discussions with the fire brigade and with the local staff i see so it can be taken from that the lfe did
00:21:11 it can be taken from that the lfe did not provide you with a copy because you didn't ask for it that's that's likely to be the answer yes and you didn't ask for it just to say that we're clear because you've had a lot of discussions with the lfb yes and we've met them on site on at
00:21:22 yes and we've met them on site on at least one occasion subsequently um the operational crews and the fire safety team so i i didn't think i thought i had been told everything that could be disclosed but that was an error right but you you knew i think didn't
00:21:33 right but you you knew i think didn't you that the lfb would produce a formal document such as this in relation to a primary fire incident yes and i have ordered them um on a number of occasions so this was just an oversight yeah i see i was going to ask
00:21:45 oversight yeah i see i was going to ask you that because clearly it was important to you to have a written record
00:21:48 record a formal record from the lfb of very far such as this indeed yes presumably it was also necessary for carl stokes to have all the information about previous fires in this building in order for him to
00:22:01 in this building in order for him to perform his fire risk assessment yes and as i say i i can't give an explanation why i didn't provide that to him right um i would have happily done but he should have do you except you should have done yes absolutely yes
00:22:13 have done yes absolutely yes okay um now if you look at page three there's a point here um on page three if you look
00:22:20 you look down uh page three you can see about halfway down your screen there's a question where active firefighting systems present answer yes type of active system
00:22:32 answer yes type of active system uh smoke ventilation location of system in relation to the fire on the same floor as fire did the system operate no
00:22:43 as fire did the system operate no and then underneath the words in brackets
00:22:47 brackets impact of the system on the fire did not contain control reason the system did not function as intended fault in system was that not a was that not an important piece of information
00:22:58 piece of information for you to know or at least for you to know that the fire brigade knew and had recorded
00:23:02 recorded yes but i think in reference to the email that i sent to we've been very clear about the floors that it failed and provided the detail that our building services manager was able to to give so we were already aware
00:23:14 able to to give so we were already aware of this
00:23:16 of this and similarly that piece of information the fact that the lfb had recorded it in a report such as this to be passed on to carl stokes yes yes now in your statement you refer to tunde
00:23:28 now in your statement you refer to tunde awaderu requesting a copy of the lfb report in 2012. did you ask the lfb for a report on that occasion
00:23:36 occasion well i mustn't have done why is that i can't give you an explanation at this point i
00:23:42 point i regularly requested these i can only think that as i said already we'd had such detailed and protracted discussions with the fire brigade
00:23:50 brigade and with the local on-site staff fire safety team and the operational crews i think i must have as wrongly as it turns out assumed that i already had comprehensive information from the people who attended
00:24:01 information from the people who attended who who are feeding into this report i thought i had it all at my disposal well you may have done but you see mr aoderu was after something like this why not just ask for it and give it to him rather than relying on a stock of
00:24:13 rather than relying on a stock of information held piecemeal by you and your records well i can't give you any other explanation other than what i've said apologies i i should have done this and i didn't right and was that what was not the fact that mr awaderu
00:24:24 that mr awaderu uh who was a resident of this building uh
00:24:27 uh important in your thinking here well yes and i i gave him as much information as i reasonably had to hand and could provide i wasn't saying no you can't have any i was trying to
00:24:39 no you can't have any i was trying to accommodate his request but as we've established i i must have not ordered a copy of this report so i couldn't give him that but i gave him everything that i could
00:24:50 could did you tell him that the aov was faulty uh
00:24:54 uh i i sorry without looking at the letter that we sent him i can't i ca i can't tell you sorry i'd have to i'd have to look back at the letter i thought that we had i thought we'd been clear that
00:25:05 clear that there were faults on the system and what i was advised is that we were aware of those
00:25:10 those the works had been ordered unfortunately there'd been a delay in the parts being available which had caused um a few days delay and my building services manager was
00:25:23 my building services manager was um chasing the contractors to get it done a few days after the fire and then was also going to do a smoke test in
00:25:30 test in conjunction with the discussion with the fire brigade it was agreed that that was what was important so so we were trying to to address the concerns and the issues right we'll see how this eventuates can
00:25:41 right we'll see how this eventuates can we stick with this document and go to page five please you'll see at the foot of page five uh in the prepronouncement entry there there's a question number of persons injured including those both injured and
00:25:52 injured including those both injured and rescued
00:25:53 rescued and there's a number three there do you see that yes uh do you agree that that three people were injured in that fight that's what it says here yes yes now you'll report by email of
00:26:04 yes yes now you'll report by email of the fifth of may 2010 that we looked at to coleto horror doesn't mention anyone being injured can you explain why that no other than as i've said we we had protracted discussions with the
00:26:16 we had protracted discussions with the operational crews who attended and at no point did they ever tell me that anybody was injured my estate staff who based on on the estate um their housing management team had talked to lots of the residents and
00:26:27 had talked to lots of the residents and had fed back um and all of that information was put into my email to coletta herrera so at no point
00:26:33 point was anybody telling me there were any injuries um which is bizarre because it would have been the operational crew who fed into this document but it wasn't brought to my attention well it wasn't brought your attention
00:26:44 well it wasn't brought your attention because you didn't ask for the document no but the point i'm making is is that the operational crews the information in this document comes from the operational crews who attend the fire
00:26:54 the fire and we were talking to them and to their um team leader um at length on site about the details of the fire and we we got a lot of information about the fire but at no point did it include the number of
00:27:05 point did it include the number of injuries
00:27:06 injuries it would have been useful to have this document because the lfb's records show that three people were injured i can see that yes uh carl stokes told us that he hadn't seen this document and as a result he wasn't aware
00:27:17 as a result he wasn't aware that three people were injured in that fire that's day 139 page 7 lines 14-23 uh clearly that must be right it must be right because i wasn't aware and i couldn't have told him
00:27:29 couldn't have told him um now can we look then at tm010048 this is your uh email report to coletohora paragraph two again just back to that um
00:27:43 just back to that um sorry this is a different email yeah
00:27:50 yes sorry i'd like to go back to the email we were on to colette o'hara which uh is at
00:27:59 page four of this email run i'm so sorry it's the same document um i've given you the wrong reference it's page four um if we go back to that paragraph two um you i've read this to you before
00:28:10 you before you tell her about the smoke logging um it looks
00:28:13 it looks is this right that the aov system simply cleared the relevant lift lobby only to circulate the smoke back into other lift lobbies on eight other floors
00:28:24 on eight other floors um what i was advised is there was a problem with the um the ceiling around the edges of the of the extraction vents on these floors and so it allowed a degree of smoke i've
00:28:36 and so it allowed a degree of smoke i've no idea how much i assumed it was not a significant amount to leak onto those floors so instead of extracting it from the building it was allowing some spillage at those points well uh on its face it says in terms
00:28:49 well uh on its face it says in terms doesn't it that the the system cleared the relevant lift lobby but in turn circulated smoke some smoke at least back into other lift lobbies in total eight yes that's what i said yes it was my
00:29:01 yes that's what i said yes it was my question arising out of that basic observation is that was that not a sign to you of a serious malfunction in this system
00:29:09 system clearly yes there's a problem in the system and i'm asking the building services
00:29:14 services team who manage the contractors and uh maintain the system what on earth went wrong and and what how did this happen and how is it being addressed and i also tried to reflect that in the email
00:29:27 tried to reflect that in the email does that not also did that not also present
00:29:31 present a suggestion to you that interim measures were needed um i don't know if it's on this email but yes and that's what our then building services manager keith field
00:29:43 building services manager keith field i took him to task about the fact that the system he knew the system was problematic and there'd been a delay in getting the remedial works done and he should have at least as a minimum
00:29:55 and he should have at least as a minimum advise the fire brigade but interim measures should have been considered and i'm sure that i've read the email correspondence on that so i think there is evidence to that effect we'll come and look at this right now if we go to paragraph three of this very email
00:30:06 paragraph three of this very email which starts the smoke extraction system is maintained under our fire safety plan preventative maintenance contract with rge services then four lines up from the bottom of page four you say
00:30:17 page four you say as discussed in retrospect the delay should have caused us to consider what if any interim measures were required until repairs were completed and the system was fully operational again i've spoken to the tmo senior
00:30:28 again i've spoken to the tmo senior engineer and advised that i believe as a minimum we should have advised the local area housing team of the local fire station manager of the defect and kept them appraised of progress and completion target for remedial
00:30:39 remedial remedial works etc um so that's what you say about
00:30:43 say about about interim measures let's just pursue it a bit further in the same email run if we go to page two we see that spencer sutcliffe
00:30:53 who was team leader for kensington and chelsea fire safety responds to your email
00:30:59 to you and to colette o'hara on the 6th of may the next day and the email is there dear janice thank you for your response regarding the fire safety failings at grenfell tower and if we go to the third paragraph down
00:31:11 and if we go to the third paragraph down he says this i appreciate your comments regarding the admission of interim measures and endorse your future recommended actions i recommend that there is an assessment made for each individual fire
00:31:22 assessment made for each individual fire safety maintenance issue to ensure that higher priority areas are dealt with to a strict time scale did you introduce a procedure to assess each fire safety maintenance issue and
00:31:33 each fire safety maintenance issue and priorities higher prioritize higher priority areas i didn't um but this would have gone to keith field who managed the contractors um and he would have been required to
00:31:47 um and he would have been required to speak to his contractors and agree agree exactly that identify which repairs which remedial works needed to be done in which time scale it should have already been covered in the contract so he should have been reviewing his contract
00:31:58 have been reviewing his contract yes no doubt but i'm asking a slightly different question did the tmo introduce a procedure to assess
00:32:06 assess the priority high priority areas in the way that mr sutcliffe is recommending not holistically no at all um well
00:32:17 not holistically no at all um well we are okay um
00:32:23 we we always looked at priorities repairs
00:32:26 repairs on it on its own but also remedia works in terms of contracts there were always very specific emergency urgent different time frames for different kinds of of repairs so it was being reassessed on a regular
00:32:37 so it was being reassessed on a regular basis um
00:32:38 basis um certainly whenever the plan preventive maintenance contracts were being re-tendered and re-procured i'm confident that it was included at that stage in relation to those specific pieces of kit but as i say that wasn't and that would
00:32:50 but as i say that wasn't and that would have been managed by the the contracts management team but i certainly know response repairs were always very specific there was some some were a four hour response somewhere 24 hours so depend depended they were always being reviewed to make sure that
00:33:01 always being reviewed to make sure that we had the right repairs in the right category
00:33:04 category was a procedure for interim measures introduced pending repairs of any fire safety mechanism um i think it's actually in in our eventually went into our policy
00:33:15 in our eventually went into our policy that it did um in november 2013 this is now uh this is
00:33:19 is spring 2010. yes i appreciate that um my point is that at this point i um was spoke at length to the building services manager
00:33:30 services manager and then we had um health and safety asset
00:33:35 asset equivalent of their sort of operations group and it's the kind of thing that i was continually reiterating
00:33:43 because i didn't always know when there were defects in advance this fire i wouldn't have been aware that there were their faults on the system um so but but keith also knew that there
00:33:54 um so but but keith also knew that there should have been interim measures to be fair there'd been a delay in the works being carried out which he hadn't anticipated which may have impacted on him not putting something in place but it brought it very heavily into the spotlight and there was
00:34:05 heavily into the spotlight and there was quite a significant discussion about it
00:34:11 well let's see how it goes um if we go up to the next page page three or down rather to the next page page three at the top uh spencer sutcliffe
00:34:23 uh spencer sutcliffe says after liaising with our fire engineering department it's surprising that if all systems are in place defective seals would cause cause this level of smoke seepage consideration
00:34:34 level of smoke seepage consideration should be given to the entire system for example did any other floor vents open
00:34:40 open did the top vent open correctly is there sufficient draw in the first place to enable smoke to travel vertically due to the catastrophic failure of the system i would suggest that it would be
00:34:51 system i would suggest that it would be very difficult to demonstrate compliance without a full engineer smoke test now did spencer sutcliffe's comments there that i've just read to you cause you any concern about the state of the aov at that time
00:35:03 aov at that time oh yes they're really quite um extremely critical
00:35:07 critical yes and if you go up to page one we can see your response
00:35:13 you say thank you for your email i referred most of your queries to my senior electrical engineer and he's responded as follows and uh there is a response there in quotations in three four rather paragraphs yes
00:35:26 three four rather paragraphs yes uh he denies the fact as you can see in the third paragraph that there was a catastrophic failure uh and then in the last um but one paragraph he says i can confirm
00:35:38 but one paragraph he says i can confirm that the work the works to the events were completed on schedule last friday and that a successful smoke test has also been undertaken however my colleague has asked for this to be repeated whilst he's in attendance and this is currently being
00:35:50 and this is currently being arranged that's your email to him now uh if we go to rbk three through
00:36:02 this is
00:36:06 a report also dated 12th of may 2010 so the very same day as your response and it's a maintenance report produced by
00:36:17 it's a maintenance report produced by rge services for the smokebench system at grenfell tower
00:36:22 tower um have you seen that document before now i don't think so now right no okay um so you haven't seen it before
00:36:30 before but let's go and look at page seven and see how we do can we go to page seven please
00:36:35 please and look at comments and recommendations under section four of this report it says there we found that the inlet dampers could not be reset with our new reset tool because the leverage required to reset
00:36:46 because the leverage required to reset was said great but to achieve this the fascia grills had to be removed the solution to this is to replace the spring actuators with electrically operated linear actuators which would apply allow the
00:36:58 actuators which would apply allow the dampers to motor open in a fire and then motor closed when the system is reset and then this due to the spring force on the inlet dampers the actuators are not reliable and may not open on every
00:37:09 reliable and may not open on every activation the outlet damper have very little force and are reliable apart from the above and its age the system is generally in good operational order and is capable of me being maintained for the next five years apart from the
00:37:21 for the next five years apart from the inlet dampers in bold you see that yes now were you aware that rge had concluded that the aov may not not operate on every activation before you wrote to the lfb the same day
00:37:33 before you wrote to the lfb the same day i've never been aware of this otherwise i would never have written that email i was given the information by the team who managed the contractor and
00:37:42 and my emails and my correspondence with the firework were based on what they were advising me well can you account for how it came about that you didn't see this report and wrote to the lfb in ignorance of it
00:37:53 and wrote to the lfb in ignorance of it no other than it wasn't provided and i took it on good faith but just explain to us how the system worked within the lfb uh within the tma that a report such as
00:38:05 uh within the tma that a report such as this could not have made its way to you because there's in those days it was building services and subsequently contract management there's a whole team within the technical division which is
00:38:16 within the technical division which is exclusively dealing with planned preventative maintenance of all sorts of pieces of kit whether it be
00:38:23 be electrical gas water quality fire safety all of those issues you usually have had a dedicated contract manager for each different aspect they
00:38:36 for each different aspect they procure the services manage the contractor monitor their performance instruct them and i would meet with the head of
00:38:44 head of on a regular basis to get feedback get a bit of an oversight of what's happening i i
00:38:49 i i i can't be looking at i mean i don't have access to and but i can't be looking at the service reports we have people whose sole job is to do that so i'm taking my sorry to
00:39:00 taking my sorry to just to reiterate so i'm taking the information i'm given by their manager who controls that team on good faith which is what i'm kind of it seems reasonable to do so you would
00:39:12 it seems reasonable to do so you would have expected senior electrical engineer who reported to you and which you reported in turn to the lfb to have told you about this report well yes he knew this was
00:39:22 this was really crucial um and we needed to address it because it was obviously a weakness on the system on the day of that fire i i wasn't before that aware that there was an outstanding repair so i was
00:39:33 was an outstanding repair so i was chasing him on a regular basis um and i was passing on his comments as you saw from the email to spencer sutcliffe i was directly quoting what his response was that wasn't my words those were his
00:39:45 wasn't my words those were his indeed but you went on to say you could confirm the works to the events were completed on the schedule last friday were you not interested to see a report from the people who'd done the work so that you could satisfy yourself
00:39:56 that you could satisfy yourself even it's just by even if just by a quick spot check or a read uh that what had been done had been done properly so as to address the lfb's concerns
00:40:05 concerns um looking at this now then clearly i should have done that i can only reiterate that i took it on good faith and um we had protracted discussions
00:40:16 and um we had protracted discussions and i was very clear about the approach that i believed they were taking so no point did it did i question further than that what they were telling me now can we go to tmo double zero eight nine
00:40:27 to tmo double zero eight nine four three one one please
00:40:36 this is a further report maintenance report
00:40:40 report for grenfell tower produced by lge services limited date of the ninth of august 2011. so that's a year on and you can see the date there if you go to page five well first of all
00:40:51 if you go to page five well first of all i should ask you have you ever seen this document before no again no right well again let's see how we go with it if you go to page five we can see that uh section three says
00:41:03 we can see that uh section three says this test results stroke urgent recommendation we've now been maintaining this system for over 12 months and can no longer guarantee that the system will operate as required or that it meets fire regulation the issues are one lobby vent systems
00:41:15 the issues are one lobby vent systems actuation are no longer reliable two lob events can and have been found to open between visits on every occasion we have found that random lob events are opening with and remain open between our maintenance
00:41:26 remain open between our maintenance visit
00:41:27 visit and then this in cats bold and underlined we cannot guarantee conformity with fire regulation and i read it like that because that's how it reads on the page
00:41:38 how it reads on the page actuation systems are not fit for purpose and must be replaces to the system to meet the fire regulation now you've not seen that before um you would agree with me i assume
00:41:50 would agree with me i assume that this is a pretty damning and unequivocally damning report about the state of the a vista aov system in august 2011. yeah yes uh
00:42:02 in august 2011. yeah yes uh you've never seen it before that explains no doubt why this was not made available to carl stokes indeed uh and you would accept no doubt that this would be information for him to have included in his fra assessments
00:42:14 to have included in his fra assessments the next one of which was on the 20th of november 2012 yes yes absolutely i mean can i just say that
00:42:20 that i was aware obviously the fire had brought to light that the system there were starting to be problems with it it was old it was clunky and i was um pushing the the building
00:42:31 and i was um pushing the the building services engineers to push for budget so that the system could be replaced but i wasn't aware there was this degree of concern or um being raised by the the contractors so
00:42:43 being raised by the the contractors so i'm aware that for a number of the health and safety meetings i was saying how are we getting to that have we procured and and they'll reflect that i was pushing for that but i wasn't on the basis that the system couldn't be relied upon we just thought
00:42:54 upon we just thought it's getting old it needs replacing can we go to tm00869798 then please and
00:43:05 then please and bear in mind that this is 9th of august 2011 this report what i'm now showing you uh is a minute of the asset investment in engineering health and safety group
00:43:16 engineering health and safety group uh the following month say five weeks later 15th of september 2011 present keith feifield and you in the chair
00:43:25 chair and doing the minutes yes oh yeah so i was
00:43:29 was yes well you sound surprised no i think john bora used to always minute these and so i
00:43:33 and so i um i didn't realize that i stepped in he was he was apologetically absent yes or at least sent us apologies uh now if we go to paragraph 2.2 you can see uh mata's not
00:43:46 paragraph 2.2 you can see uh mata's not matters arising not on agenda can you see that
00:43:50 see that yes and if you go to the very foot of the screen under e previous minute 10.2 it says this replacement of ventilation and extraction system at grenfell tower
00:44:01 extraction system at grenfell tower detailed design including the fire alarm and smoke ventilation now received works to be tended imminently for december 2011 start on site kf confirmed that the auto dialer for remote
00:44:13 that the auto dialer for remote monitoring of the system when concierge staff are not present is to be arranged separately and in advance of these works jw reiterated that this is urgent and asked kh to update her asap with a time scale
00:44:27 to update her asap with a time scale action k5 field
00:44:34 now uh you can see that discussion there just moving on then um you're
00:44:43 um you're pausing that actually you were aware from those minutes at the very least that that
00:44:48 that that work was going to be happening on the aov yes that that's exactly what i'd yes and but that's exactly what i was just referring to that is we were pushing for it to be replaced right is it the case
00:44:59 replaced right is it the case that you did not have this report at this meeting i did not have this report but we had had the fire and and my understanding was that this piece of kit was not going to last forever
00:45:11 of kit was not going to last forever and i think it was originally for when the building was built and it's an important piece of fire safety kit i wanted to make sure that it was always top of the agenda when they were budgeting so i took every opportunity to say
00:45:21 say where are we at with this have we done the procurement have we done the design i i kept on kind of pushing it forward yes why was it all so urgent such that the works had to
00:45:33 all so urgent such that the works had to be tended immediately if the system was old but still operating because procurement is really slow
00:45:39 slow and that you need to get all of these this expedited it can take months and months to go through all of the tendering processes to make sure that you're compliant with the contract regulations
00:45:50 regulations um and the su so i i was just trying to make sure that everybody treated with degree of urgency so that the system didn't fail before we were in a position to replace it can you think of any reason
00:46:01 replace it can you think of any reason why keith firefield would not have brought the rge services report of the 9th of august 2011 to your attention in the context of this very discussion at this meeting five weeks later no just that he routinely didn't give me
00:46:13 no just that he routinely didn't give me servicing reports and i was probably busy doing other things and and didn't routinely ask him and
00:46:18 and trusted what he was telling me in good faith when he was summarizing where he was at with each of his contracts but this is this is not just uh a servicing report is it this is a servicing report a maintenance report
00:46:30 a servicing report a maintenance report which contains in it in bold underlined in caps a a strongly worded message that your aov system at grenfell tower is non-compliant with the building regulator or with the fire regulations
00:46:42 regulator or with the fire regulations whatever that might mean can you explain why mr pfeiffer would have kept that from you no i can't and it's frustrating for me because i i genuinely don't i'm confident that
00:46:53 i i genuinely don't i'm confident that i've never seen it i don't know why anybody would have kept it from me so i mean this reflects that i had concern and i was trying to push it forward but my concern wasn't based on the full picture it seems now
00:47:05 picture it seems now i i can't answer for him sorry i don't know what
00:47:09 know what um reason there would have been i i'm i'm not asking you to answer for him i'm really asking you to answer for the tmo but also asking you to answer yourself and really ques to dig deep into your memory really
00:47:20 memory really tell us whether you're really sure you didn't see this night of august 2011 report i'm sure i didn't see it okay um can we go to tma1 triple zero two two one seven
00:47:36 these are minutes from a meeting with you which you had with keith firefield on the 16th of january 2012. uh if we scroll down to page four just
00:47:47 uh if we scroll down to page four just for your benefit we can see that you signed these minutes with your name and your role there so we know that they're yours can we then um go back please
00:47:58 can we then um go back please to the first page just to identify the document better um do you recall seeing this document at the time i think you drafted it so i drafted it i would have regular meetings with keith fifield just um
00:48:09 with keith fifield just um to make sure that i knew what was happening in his team and i could raise issues with him so i would have drafted this yeah yes uh and if we go to page
00:48:20 yes uh and if we go to page three we can see item 13 grenfell tower the replacement of the extraction extraction and ventilation system at grenfell tower is being tendered however janus is anxious to get the
00:48:31 however janus is anxious to get the remote monitoring of the communal fire alarm at this block actioned i should say urgently so again is this discussion happening
00:48:42 so again is this discussion happening between you and mr field with you in ignorance
00:48:46 ignorance of the 9th of august 2011 yes it's remarkable that isn't it well it is now as we sit here but i i could only act on the information that i had available at the time um and i was i mean that's the point i
00:48:58 um and i was i mean that's the point i was making that i was hounding and i was bugging him about it constantly because it was it was on my agenda and i thought it was really important
00:49:05 important that that we progress it and the monitoring thing also took too long to put in place um so this this is one of my opportunities to to raise it and and minute it and and
00:49:18 to to raise it and and minute it and and no i i mean i'm just thinking standing in here as i am asking you about this i mean there really are there are only two possibilities aren't they either you've forgotten the fact that you saw the 9th of august 2011
00:49:30 that you saw the 9th of august 2011 report which is possible uh or else keith feinfield deliberately concealed it from you and and effectively misled you now if you can think of another possibility
00:49:41 you can think of another possibility do please tell me what that might be
00:49:47 i i i'm confident i haven't seen it but also
00:49:50 also everything that you've shown unless you show me something that proves that my memories escape me everything you've shown me so far indicates how i would phrase things when i i thought that they they needed to be addressed but it's not
00:50:02 they needed to be addressed but it's not saying
00:50:03 saying this isn't operational or i'm i'm sure that if i had seen that report these notes would reflect my enhanced concern because i've seen that and looking back on it do you
00:50:14 and looking back on it do you sitting here now have any reason to think that keith eiffel would have misled you deliberately no you trusted him yeah i trusted him yeah
00:50:24 yeah now um can i ask you then please to go back to your first statement
00:50:31 statement and go to page 44 paragraph 201 again which is where you we see the correspondence from tundial dairy referred to yes
00:50:42 tundial dairy referred to yes and you've exhibited jw 43 14 november 2012 email um were you aware at the time that the grenfell tower leaseholders
00:50:53 that the grenfell tower leaseholders association which was the organization that mr awadari represented also made complaints to jeff payne and robert black at the tmo in the same year 2010 same year as the
00:51:04 in the same year 2010 same year as the fire 2010
00:51:05 fire 2010 about the fire among other things um i'd i'm not sure whether i was it's it's possible i was i can't really be honest did daniel wood
00:51:16 i can't really be honest did daniel wood or robert black or or anthony parks or anybody else at the tmo discuss with you your investigations into the 2010 fire before responding to the to to uh mr abujaru do you know
00:51:27 abujaru do you know um i think i think i would have spoken to daniel wood and possibly david ward who
00:51:32 who often responded um just to to give them um the history and all the information that i could give them right um i'm not sure whether i spoke to
00:51:43 right um i'm not sure whether i spoke to robert about it it's possible but i don't recall
00:51:50 right did you bring home to mr black the fact that the aov system was not functioning or at least not functioning properly so far as you knew it
00:51:57 knew it uh and had not functioned properly so far as you knew it uh at the april 2010 fire um i'm i think i circulated
00:52:08 um i'm i think i circulated the the email to coletta harrah which had the details as they've been presented you're right and pretty widely yeah so i'm sorry i can't recall it's possible that i did but i really can't recall but i mean it was
00:52:20 i really can't recall but i mean it was pretty explicitly stated that there had been a failure in the system at that point in time um it's possible somebody phoned me up and asked me more questions but i just can't i can't recall i'm sorry
00:52:31 just can't i can't recall i'm sorry now can i ask you to go to tmoh three zeros two seven two zero eight
00:52:39 this is an email uh well if we go to page three actually where we need to start with that and on page three halfway down the page we can see that there's an email from you to paul duncan 22nd of november 2012
00:52:51 paul duncan 22nd of november 2012 under the subject fire safety inquiry from grenfell tower hi paul as discussed attached as a copy of the email i sent to the lfb safety team following the grenfell fire on 30th of april 2012.
00:53:02 on 30th of april 2012. yeah uh i i i that may well be about it is a typo for 2010 isn't it yes it is yes and if we go to page one we can see the last email on the page
00:53:13 we can see the last email on the page there
00:53:14 there is from paul duncan to you and to daniel wood on the 30th of january 2013 saying please find attached draft response to grenfell tower leaseholders association's fire safety inquiry
00:53:27 association's fire safety inquiry janice i think we may need more info on item three okay was your was your email originally uh to assist paul duncan in responding to the gtla
00:53:37 the gtla um i believe so yeah i don't think paul would have known the detail of the fire unless i provided it to him yes i see so i think so
00:53:46 uh did you ask for an update on the state of the aov at that stage when responding i honestly don't know right so you
00:53:57 i honestly don't know right so you didn't go back to keith feifield and say what is the current position please with the aov i i honestly don't know whether i did or i didn't um i can't recall doing so
00:54:16 if we go up to
00:54:23 uh item if we go up to i page two which is the
00:54:31 um next email we see we se you send a further email on the 25th of january 2013 to paul duncan and daniel wood below is the info i extracted from my email to the nfb attached summarizing
00:54:42 email to the nfb attached summarizing the fire at grenfell on 30th april 2010 which was included in the previous response to the grenfell leaseholders i remain a view that it is not appropriate to disclose this email
00:54:53 appropriate to disclose this email having originally discussed this with janet seward who is of the same view however in response to the specific points raised up and advised as follows and then um if you look down
00:55:04 and then um if you look down to one you can see this fire brigade reports in relation to the incident dated 30th of april 2010 i've checked with the lancaster west estate team who did request a copy of this report at the time that they do not think they ever received this however i would add
00:55:16 ever received this however i would add that these are standard pro formas with various sections redacted and can be of limited use we found it to be much more beneficial to meet with the lfb to discuss the details of the incident and as previously advised this is what we did that goes back to i think
00:55:28 we did that goes back to i think your evidence earlier does it yes that's why you didn't contact the lfb to ask for a copy nonetheless d do you accept that this appeared to be an issue of ongoing concern for the gtla
00:55:40 concern for the gtla so why not just ask the lfb for that report
00:55:43 report at that point have they been asked for it um it
00:55:46 it um it it appears that my my colleagues on the lancaster west team had done so um yeah i mean as i read it now then why didn't i
00:55:54 didn't i i can't give you an explanation i should have done i think in good faith i thought my colleagues had already requested it um and i can't give you any other explanation i'm sorry okay and then if
00:56:05 explanation i'm sorry okay and then if point four instruction or recommendations made to the kct most emb recycling arrangements were investigated by the lanc west team and modified in consultation with rbkc works to repair the
00:56:17 with rbkc works to repair the ventilation stroke extraction system which were due to commence the following week with progressed and further investigations undertaken on this system to ensure there were no other areas of concern the lfe were given a briefing on
00:56:28 concern the lfe were given a briefing on this system and again why there you don't mention the fact that the aov system was in need of repair why is that because i've said works to repair
00:56:38 repair the vented and i i think the inquiry was specifically had lots of questions very specifically around this fire so i was responding to what we did and what we found when we investigated
00:56:50 and what we found when we investigated this fire
00:56:52 this fire and so that's what i'm referring to works to repair the ventilation extraction system which we're due to commence the following week were progressed and further investigations undertaken on the system because that's what i've been advised by
00:57:04 what i've been advised by on my building services team yes and clearly
00:57:08 clearly you're not having the rge 9th of august 2011
00:57:13 2011 report no and what it said meant that what you say there was a grotesque understatement
00:57:20 yeah and therefore the residents of grenfell tower were living in a building with an aav system which had effectively been condemned as non-compliant by the maintenance
00:57:32 non-compliant by the maintenance engineers
00:57:34 engineers but were doing so in ignorance we're living there in ignorance of that fact that's i can't dispute that but i didn't have that information so i
00:57:46 but i didn't have that information so i couldn't have provided it um yeah rge was saying they couldn't it can be relied upon so it's functioning to some degree but i don't know how to
00:57:57 don't know how to what degree because that hadn't been brought to my attention
00:58:02 and you hadn't pressed keith myfield for an rge report up to date so that you could give residents the up-to-date position no it seems i didn't
00:58:16 now let's move forward into the next year
00:58:21 year and look at march 2014 uh lfb three lfb three zeros three two one zero one please
00:58:34 this is a letter dated the 24th of march 2014 from
00:58:40 2014 from the lfepa by which the tma was issued with a notice of fire safety deficiency under the regulatory reform order the rro
00:58:49 rro and we can see uh at the bottom of page two if we go there please that you were copied into this personally you see that yep and if we go to page three in the letter
00:59:00 and if we go to page three in the letter in the schedule uh next to article 11.1 the nfb say this failure and the effective monitoring of preventative and protective measures
00:59:11 protective measures for example a significant number approximately 25 percent of automatically opening vents within the common parts of the premises were found not to be in working order no suitable system of monitoring was in evidence to
00:59:23 system of monitoring was in evidence to identify
00:59:23 identify deficiencies with the smoke ventilation system
00:59:27 system and the notice says implement effective monitoring of preventive and protective measures and if you go to the next item down article 17 it also i'm summarizing
00:59:39 article 17 it also i'm summarizing directs the tmo to ensure that adequate maintenance systems are in place to ensure that the premises and only facilities equipment and devices are maintained in an efficient state in effective working order and good repair
00:59:50 good repair you see that yeah and that's actually a quotation not a summary of what they say and then on page three article 21 at the foot of your screen if we could just down a little bit yes
01:00:01 if we could just down a little bit yes thank you
01:00:01 thank you failure to ensure uh employees receive adequate
01:00:05 adequate safety training staff on site did not appear familiar with actions to be taken in response to the fire safety system explains why now none of these issues
01:00:18 why now none of these issues is this right had been had been raised by carl stokes previously in any of his fire risk assessments for grenfell tower either in november 2012 or before that
01:00:29 either in november 2012 or before that uh i don't think they were i know no we can't see them there um nonetheless can we move on to cst four zero three one
01:00:41 move on to cst four zero three one double zero
01:00:48 now the letter i've just shown you is dated the 24th of march this is a letter from carl stokes the previous week 18th of march 2014 to claire williams
01:01:01 18th of march 2014 to claire williams uh and it says premises grenfell tower and
01:01:04 and the other buildings on the lancaster west estate and he says thank you for asking me to comment on the questions raised by the london fire brigade lfb officers during their visit to the above buildings on the lancaster west estate
01:01:16 buildings on the lancaster west estate on 12th of march and then if you go to page two
01:01:23 i i i i and he says in the in the first paragraph we've skipped away from that he visited on the 17th of march which was the day before his letter uh he says on page two
01:01:34 he says on page two the very top of the page the emergency smoke control extract panel was showing healthy when looked at yesterday with the switch in the auto position
01:01:45 position and then he goes on to give more details about that now the letter is addressed to claire williams as we've seen did you see the letter
01:01:53 letter yes time you did how come did she did claire williams pass it on to you um carl was inclined to copy me into not everything he did but um most of
01:02:04 not everything he did but um most of what he did right now as i've shown you his conclusion in his letter here about the monitoring and inspection of the aov
01:02:15 namely that it was showing healthy and up to date and there were no issues appears to be at odds with the lfb's conclusion in their notice of deficiency the following week
01:02:26 notice of deficiency the following week that there was no adequate maintenance system in place next to the notation under article 17.1 that's right isn't it
01:02:33 isn't it um yes i think i think he recommended that we
01:02:37 that we we bring forward the next plan preventative maintenance servicing and that's what he requested um
01:02:44 um so that there'd be an independent specialist check on the status were you not concerned at the time
01:02:51 time but uh by at least an apparent inconsistency between what carl stokes was was advising and what the lfb then did the following week
01:03:02 did the following week well um so i think the the lfb had actually been on the 12th but didn't we didn't get their paperwork until the 24th or whatever so cole claire has asked carl to attend
01:03:15 so cole claire has asked carl to attend and investigate the issues which were raised
01:03:20 my understanding is that he commented on the supply saying healthy but that he recommended that we bring forward the the servicing so that that we would have
01:03:32 the servicing so that that we would have the specialist contractors look at the system to make sure that because he's obviously not going to be testing the system but we need to investigate more thoroughly and so that's what he recommended we do which will have been
01:03:44 recommended we do which will have been what um we asked the contract management team to do so that so that we had um we had a proper assessment of of the condition of the alv were you not
01:03:57 the condition of the alv were you not let me just press you for an answer were you not concerned that there was at least an apparent inconsistency between what mr stokes was saying namely that
01:04:05 that the emergency smoke control extract panel was showing healthy and up to date and no issues on the one hand but the lfb uh was saying that it wasn't because a
01:04:16 uh was saying that it wasn't because a quarter of the vents weren't working
01:04:20 i don't think he was saying it's okay i think what he says about the supply healthy
01:04:24 healthy does seem to be worn out by the photograph but he recognizes that he isn't in a position to to um assess in the way that the specialist contractors will so they can test a system where he's not really able to
01:04:35 system where he's not really able to um so i think he he recognized limitations of his visual survey and was recommending that we get the specialist contractors into check which i think was the right thing to do
01:04:51 you're asking me about inconsistency yes um were you struck by an inconsistency
01:04:58 i would have expected if um the fire brigade are saying 25 percent of the vents don't seem to be firmly closed or partially open i would have expected that to be reflected in carl's report
01:05:09 reflected in carl's report indeed but because he has identified that disney's looking at by a specialist contractor then at least he's recognized that his visual inspection isn't the end of the story that we need to do more thorough
01:05:20 story that we need to do more thorough checks
01:05:30 now in
01:05:34 if we go down to
01:05:42 page 11 of this letter you can see that there is a heading my comment and recommendations and under item one it says the next
01:05:53 and under item one it says the next quarterly service is imminently due on the emergency smoke extraction system etc and i would recommend that the contractor is asked to service the system sooner rather than later and any findings etc
01:06:05 rather than later and any findings etc are actioned upon if the system is in working order there's no requirement to a cfd analysis to be undertaken that's where one finds his effective conclusion and recommendations my point again were
01:06:18 and recommendations my point again were you not struck by the inconsistency between what he's saying there and what the lfb came up with only a week later or two weeks if you like after their
01:06:29 after their visit um
01:06:33 visit um i'm a struggle um i mean the lfb are also doing a visual check so i've got two people doing a visual check what i need is somebody to test the system to be able to give me comprehensive information and it seems to me that that is what i need
01:06:45 to me that that is what i need is is the specialist contractor who are engaged
01:06:49 engaged to work on that bit of kit to give us meaningful report um so i still need that i appreciate the point you're making that carl hasn't commented on events being
01:07:00 carl hasn't commented on events being open and he has commented on the supply being healthy um i didn't take that to be contrary to what the brigade was saying what i took it to me just to back up the fact that we needed we needed a proper
01:07:11 fact that we needed we needed a proper report by people who understood the system and could service it or maintain it so that we had an accurate view of the status or
01:07:22 an accurate view of the status or condition
01:07:23 condition and were you yourself concerned that although there had been at least as reported to you repairs done at the end of 2012 early 2013
01:07:34 2013 uh the aov system in grenfell tower was now playing up again to such an extent that it had been the basis of a notice of deficiency in march 2014.
01:07:44 2014. i mean i think this goes back to what i've said before we we knew that the system
01:07:48 system was not going to last forever and needed attention and hence me raising it regularly to say when are we going to design a new system re-procure a new system
01:07:59 system in in preparing to come i read quite a lot of minutes from that meeting and it seems to me that we got to the point where the design was ready and the procurement was ready to go and at that point um running sort of in
01:08:11 and at that point um running sort of in parallel was the decision to do the refurbishment works at grenfell tower um and went okay i'll take that bit of work and incorporate it into so i think
01:08:22 work and incorporate it into so i think um in retrospect that did cause a delay in dealing with the aov i think i believe
01:08:28 believe from what i've read that we were at the point where we could have done the replacement works um as part of you know by the building services team could it could have overseen that but because the refurbishment work was
01:08:40 but because the refurbishment work was being discussed at that time that that meant
01:08:43 meant that work got parked and then got subsumed into the other work which inevitably caused a delay the system still is not going to last forever and still needs scrutiny and monitoring um and that's where i think we had got
01:08:55 um and that's where i think we had got to so i i'm if you're i'm not surprised that that it's still potentially problematic but my point is i don't know how problematic which is why i think we need somebody who's a specialist to go and tell us well were
01:09:06 specialist to go and tell us well were there any interim measures in place before march 14 before sorry march 14 before the letters of deficiency were there any interim measures not that i'm aware of because i'm still not being
01:09:17 i'm aware of because i'm still not being told
01:09:17 told i'm still not being told that it's we know that it's not going to last forever but at this stage i still believed it was functioning and so i'm not aware that they're entering measures at that point so the yellow so the lfbs
01:09:28 yellow so the lfbs elfipa's notice of deficiency letter must have come as something as a shock to you
01:09:32 to you or at least a mild surprise perhaps well yeah it i mean it did indicate that the system had um potentially deteriorated again or you know was perhaps only partially
01:09:44 you know was perhaps only partially working but i didn't know until we we got some meaningful information but yeah it indicated there's a problem and he's investigating now the notice of deficiency letter indicated well demanded
01:09:55 indicated well demanded that a cure uh be effected by the 5th of may 2014
01:10:00 may 2014 yes the recommendations had to be carried out by the by 5th of may 2014. were any of those recommendations implemented by 5th of may 2014 um i don't know the answer to that as we
01:10:12 um i don't know the answer to that as we sit here um a had produced his report that was circulated to contrast management team and anybody else who needed to action anything
01:10:23 else who needed to action anything within that um i would have been chasing for responses
01:10:28 responses i would i know i was chasing for and i i think although i may be wrong this coincided with the time that rge left and another interim contractor came on board
01:10:37 board um i think alex bosman was in post by then so it was alex who i would have been chasing um to get the servicing done to get the maintenance contractor there to identify any problems and he was well
01:10:48 to identify any problems and he was well aware of the need for interim measures and the other thing i'm aware of which is also relevant sorry i know i'm being winded
01:10:57 winded um is when um the tender was being prepared which was late 2013 for the refurbishment work um i wrote to the
01:11:08 um i wrote to the project manager to say if you are including
01:11:12 including the alv system in your works you need to be aware that if it is going to be non-operational for a period
01:11:19 period then we will need to have interim fire brigade advised um and also can this be prioritized to the very front end of the the program and i i found that email recently so i know that i did that
01:11:30 email recently so i know that i did that so i've been trying to keep it on everybody's agenda and and um be clear that it's it's really crucial it needs to be treated with priority
01:11:38 priority did you tell barbara matthews or or um well did you tell bob robert black at that point or um at this stage of march 2014 said anthony parks about the arrival of the notice of
01:11:50 about the arrival of the notice of deficiencies um i'm sure i would have done i'm sure you would have done would you have done so by email or would you have told them face to face and shown it to
01:12:01 told them face to face and shown it to them i might have shown it to him right i'm not sure was it discussed at a health and safety committee or meetings of the tmo executive or tmo board at the time do you remember um i i wouldn't have been on either of those
01:12:12 i wouldn't have been on either of those so i wouldn't be the person who could confirm or deny right did you yourself take any steps to arrange any interim measures to be in place
01:12:23 place after you had received the notice of deficiency of the 24th of march 2014.
01:12:29 um i'm not really did i i saw the interim measures as being very clearly um something technical that we would
01:12:40 um something technical that we would have to put in place to either enhance the performance of the automatic opening events or to temporarily replace it it's so it's really i see that as being
01:12:52 it's so it's really i see that as being really quite a technical matter so i saw that as sitting with either either contract management team or the project team and i would have been making it clear to both of them that they
01:13:02 that they they have specialists consultants and contractors under their jurisdiction and this is really crucial and what can we do for interim measures mr chairman it's nearly 11 15. i'm about
01:13:14 mr chairman it's nearly 11 15. i'm about to turn to a different topic i could finish that topic um in about 15 minutes if you're prepared to sit a little bit longer into the morning given the late start we had we we've had a bit of
01:13:25 late start we had we we've had a bit of a yes i ate us already haven't we yes do you feel comfortable going on for another
01:13:30 another 10 15 minutes yeah that's fine right can we try that one mr minute also transcriber as well is that well joe's always very accommodating on these things but um
01:13:41 things but um you can't write to ask yes you're right thank you very much to all of you thank you in which case let's move uh to later in the year 2014 lfb 3084118
01:13:56 this is a minute of uh a bi-monthly meeting that you attended with the lfb 13th of november 2014 at 9 30.
01:14:07 13th of november 2014 at 9 30. if we could see who is present uh suhail dada boy rebecca burton uh terry chaplin covering for dan halesey and you and if we go um
01:14:18 and if we go um to item one you can see claire williams was not there if we go to the top of page two we can see that there's a minute that says that you gave an update grenfell
01:14:29 says that you gave an update grenfell tower
01:14:30 tower janus advised that our fire consultant had now completed a review of the fra for this block this has been undertaken in close liaison with the principal contractor rydens and could be made available to the lfb
01:14:40 the lfb janus advised that riders were finding the local lfb crews regular familiarization visits to the tower to be really helpful now it doesn't seem as if there was any discussion at all
01:14:51 as if there was any discussion at all about the aov system at that meeting is that is that right um it seems to be right yes later that day let's see tmo double zero eight five two
01:15:03 let's see tmo double zero eight five two zero two eight we'll see that claire williams same day forwards use emails between her and ryden about the aov
01:15:16 and ryden about the aov okay so we go down to
01:15:22 um page three i think it's the best place to to pick this up
01:15:29 this up uh where claire williams writes to simon o'connor he was the site manager uh for the project of grenfell uh subject grenfell aov simon can you please update me on the above
01:15:40 please update me on the above one aov work at grenfell at the emily meeting the other day there was discussion over what could be done on the system could you give me a short paragraph today before our meeting with the fire brigade tomorrow thanks um and then if you go up the page
01:15:54 thanks um and then if you go up the page we can see that um i think we need to go to page two
01:16:00 two simon o'connor comes back to her copy to simon lawrence and says probably simon l
01:16:07 simon l best response to this is he's leading the design on this team and then we do get simon lawrence's response if we scroll up to page two higher up page two uh we probably need the bottom of page
01:16:19 uh we probably need the bottom of page one
01:16:21 one for the email detail we can see it's from simon lawrence 13th november 2014 to simon o'connor and claire williams
01:16:31 williams the reason i'm showing you this in detail is that higher up the chain this comes to you and we'll look at that in a moment but looking at what he simon lawrence says on the 13th of november 2014
01:16:42 november 2014 at the top of page two morning claire as per our conversation at tuesday's meeting our emini design team have been working hard on finding a solution to the aov system where we can urgently install now to
01:16:54 where we can urgently install now to greg grenfell sun protection asap we're trying not to carry out any costly abortive works but they're trying to install a part system now then upgrade in the
01:17:01 in the following months so far out of the four different specialists we've approached only one feels they are able to carry out the works to this method so no works are abortive we're currently arranging a meeting with
01:17:13 we're currently arranging a meeting with our specialists and building control to ensure everyone is in agreement with the proposed design in our initial meeting with janice and carl i said we would aim to get a part system operational by christmas we're still doing our best to achieve this but the
01:17:25 doing our best to achieve this but the early feedback from the specialists on tuesday
01:17:27 tuesday is that is unlikely to be before christmas however i'm waiting their response to tell me when i'll let you know as soon as i have some more news in the meantime you still only have the existing smoke detector and visual fire panel
01:17:38 smoke detector and visual fire panel alarm covering the building now um that then comes to you the same day if we go up to page one at 1 59 p.m
01:17:49 1 59 p.m you see that yeah second email down there
01:17:52 there uh she says sorry in training and then you just pick this up uh did you uh did you forward this update on to those from the lfb who
01:18:04 this update on to those from the lfb who had attended the meeting that morning sunil daddy boy and rebecca burton
01:18:09 burton i don't think i did no why is that i don't know actually um i
01:18:19 i can't give you an explanation um claire was by this stage the aovs were i believed under the control of the project team it was for them to
01:18:28 them to input interim measures it was for them to ensure maintenance if necessary um claire was invited to the liaison meetings so she could provide an update clearly from what you've just showed me
01:18:39 clearly from what you've just showed me the info that i had to take to the meeting was was pretty pretty minimal um and my understanding was that the project team had their own
01:18:50 that the project team had their own liaison with the fire brigade on site as well so
01:18:53 well so they were regularly updating the teams and advising them of the status of the systems
01:18:59 systems but yeah we should have advised the fire safety team as well as the operational crews
01:19:04 crews you reply if we look at the top of page one
01:19:10 uh about an hour later yeah thanks grateful for you keeping me in the loop fortunately the lfb did not raise
01:19:18 raise any specific issues on grenfell because you're i didn't have the information to give them i told them what was it what she'd given me to tell them and now this has come to light so you're right i
01:19:29 has come to light so you're right i should afford it to them but well it's more than that isn't it did did your response not mean that you were only going to update the lfb to the extent that they asked about the aov or the deficiency notice no no
01:19:41 or the deficiency notice no no i i'm not part of the project team so there's all sorts of things going on that i'm not party to which was the point of claire when she could attending the meeting so she could give them
01:19:50 give them specific updates um and i've updated with the information i've been given if they've asked me wider than that i'm unlikely to be able to to give them comprehensive information why was it
01:20:01 comprehensive information why was it fortunate that the lfb did not raise any specific
01:20:03 specific issues on grenfell because claire wasn't there to address them i don't understand the lfb didn't raise any specific issues on grenfell in the light of what you're now being told why was that lucky why was that
01:20:16 told why was that lucky why was that fortunate
01:20:20 i'm giving her feedback on the meeting there are two sort of separate issues going on here i'm giving her feedback on the meeting that she wasn't able to attend that fortunately they haven't raised any specific issues if they'd raced any
01:20:31 specific issues if they'd raced any specific issues i would have had to take them to claire and said can we get back to you because i wouldn't have probably had the information that they required because i'm not part of the project team
01:20:42 because i'm not part of the project team yeah well it isn't actually what you're saying is that it's very lucky that the lfb didn't ask you about the aav at grenfell because had they done either you wouldn't have had an answer which would have been embarrassing or you'd have had to given them the facts which would have been worse
01:20:55 which would have been worse but i didn't have the facts and that that's sorry that's the point i'm trying to make is that i i didn't have access i do now or i've certainly got a clearer stare but i didn't have them at the meeting um
01:21:08 but i didn't have them at the meeting um so there wasn't very lit much i could have told them moving on in time then tmo one triple zero eight seven nine two page one and this is
01:21:19 page one and this is the minute of a tmo health and safety operational meeting 21st november 2014. and we can see that you're present
01:21:31 and we can see that you're present among others if we go to the bottom of page one we can see if we go if we scroll down grenfell tower fire safety jw confirmed that the tmo are looking to ensure that
01:21:42 that the tmo are looking to ensure that we integrate the most recent fire safety kit
01:21:45 kit nfb are not engaging with eddie defan daphon i apologize and then if we go over the page uh it says uh
01:21:57 uh it says uh rydens have done everything lfb have asked them to do in regards to the vents rydens was sourcing a contractor to get the works done as soon as possible it is likely to be after christmas writings have explained to lfb that the
01:22:10 writings have explained to lfb that the system is beyond economical repairs and lfb are aware to be appropriately equipped when arriving to deal with fires did you know who it was at the lfb ryden
01:22:21 did you know who it was at the lfb ryden had told
01:22:22 had told that the existing aav system was beyond economical repair no and i think that's actually peter that's been quoted there because i think that's his phrase isn't it beyond economical repair
01:22:34 it beyond economical repair well you you have to tell me that is that right i believe so um right again i wouldn't necessarily have had the detail i had been pushing them
01:22:43 them to get the events whatever works had to be done to the ovs to get it done as priority
01:22:47 priority and there had always been um i believe a sort of expectation that they would try and christmas would be a target um and frustratingly christmas seems to have slipped but i i think
01:22:59 slipped but i i think the detail here is being provided by peter and not by me right but did you not understand what he meant when he said let it be assumed he did rydens have explained to lfb
01:23:10 rydens have explained to lfb who do you think he meant given that you had been attending the by the bi-monthly meetings
01:23:14 meetings who was it in your mind whom ryden had told that the system was beyond economical repair i my understanding would be that it would be the operational crews who were doing their regular familiarization
01:23:25 their regular familiarization and their and their team leader or station manager that that's what i would have believed and what
01:23:31 what to you did the phrase lfb are aware to be appropriately equipped when arriving to deal with fires mean
01:23:41 um
01:23:46 i sort of assume as i sit here now that it would be
01:23:51 be [Music]
01:23:52 [Music] um they had the right appropriate they had additional breathing apparatus or they could have had i don't know really i'm speculating they would have been aware of what the issue is and they
01:24:05 been aware of what the issue is and they i'm assuming they had some um steps that they could take themselves to to deal with the risk now this is 21st november 2014. can we take it that
01:24:16 we take it that by this point to your knowledge the lfb fire safety team had been told that the aov system at grenfell tower was beyond economical repair um
01:24:28 economical repair um claire would have to confirm who who in the life being you which was your question to me apologies um i i don't i don't know who she's advised
01:24:38 advised sorry were any other mitigating measures or any
01:24:42 or any mitigating measures discussed and agreed with the lfb at this stage
01:24:48 not to my knowledge
01:24:52 um can you explain why not i can't explain why not i can explain that i'm still pushing the project team um as as i said when the tender was being
01:25:04 as i said when the tender was being drafted i asked for it to be included that interim measures would be absolutely required and the fire brigade would need to be kept on board so the contractors have always been clear
01:25:15 the contractors have always been clear since they that part of their their schedule of work is to replace the aov then i my assumption would be that when they submitted their tender that would very clearly have their rams and their proposal for how that would be addressed
01:25:28 proposal for how that would be addressed um and yet we don't seem to be getting any interim measures that there's clearly activity where they're approaching specialist contractors and trying to get a partial system in place um but i don't know the detail of that
01:25:40 um but i don't know the detail of that so all i can do is keep chasing and chasing and also chasing alex bosman to see if his specialist contractor can put something in place but all that frustrating that's all i can do is keep chasing these individuals and saying you
01:25:51 chasing these individuals and saying you know
01:25:51 know what what else what else what what more can we do
01:25:55 can we do you know what are your all of your fire safety specialists who you've got access to what are they saying but from what from what you could see here and observe at the bi-monthly meetings up to that point in time
01:26:06 meetings up to that point in time you had not seen or heard anything which would lead you to think uh that the lfb fire safety team with whom you were liaising by monthly knew that the aov system at grenfell tower
01:26:17 that the aov system at grenfell tower was beyond economical repair yeah you're right i i hadn't seen anything today or that there were any interim measures in place to to mitigate uh again from the information i've got
01:26:28 uh again from the information i've got it doesn't look like there are but i'm i'm not on the ground um right one more email before the break if we may miss william claire williams to you uh on the 11th of
01:26:39 claire williams to you uh on the 11th of december 2014 at tm08 double zero eight five
01:26:42 five seven eight one seven please tmo double zero eight five seven eight one seven
01:26:52 we can see at the second half of the screen claire williams emails you on the 11th of december grenfell smoke vents janice at our site meeting today ryden confirmed
01:27:03 meeting today ryden confirmed you can see there and then in the third bullet point it is clear now that work won't start until the new year as works are dependent on how quickly the building control team can turn around
01:27:12 around the application you see that yes and you respond at the top of the screen we can go to that thanks claire let's hope our luck holds
01:27:24 thanks claire let's hope our luck holds and there are no fires in the meantime when will the main door be secured please advise thanks janice what did you mean by let's hope our luck holds and there are no fires in the meantime
01:27:35 meantime i would never normally worried anything like that i was utterly frustrated that having chased all sorts of people about interim measures and have highlighted the issue of the aovs definitely going to be taken
01:27:46 of the aovs definitely going to be taken down to be replaced before the tender had even gone out i have and then i've been told that it'll be done by christmas now it clearly won't be done by christmas and from what i can see
01:27:57 christmas and from what i can see there aren't significant injury measures in place
01:28:01 in place and i was utterly frustrated because what more could i have done other than keep chasing and getting people with specialist contractors and consultants and to provide technical advice i'm not an engineer so i'm reliant
01:28:13 an engineer so i'm reliant on those um so yeah by luck were you concerned because there was an increased fire safety risk to the residents posed by the absence of an operating aov system
01:28:25 the absence of an operating aov system or were you concerned because a fire would expose your own failure to ensure that one was working i was concerned about fire safety to residents to staff to contractors to anybody
01:28:37 to contractors to anybody who could who would potentially have to face it and that's why i had been banging on boring people with interim measures on the need for them and the need to consult their specialist fire safety engineers
01:28:48 safety engineers in order to get those in place and even with all of that resource in two locations we're in a position where i'm now being told not only can we have we not done that have not been able to do that but actually now the time slam
01:28:59 actually now the time slam time frame has slipped again did you think that holding do you think that hoping your luck would hold was any kind of approach proper approach to fire safety of course
01:29:10 proper approach to fire safety of course not it was a glib comment and i regret it and in my defense it's i don't normally communicate in that way i genuinely was utterly frustrated and exasperated that
01:29:23 utterly frustrated and exasperated that this hadn't been addressed leaving that on one side do you accept that the residents were entitled to expect more from you
01:29:28 from you personally uh than crossed fingers of course
01:29:33 course mr chairman is that a convenient moment yes thank you i think it is we'll have a break now miss ray uh we'll come back to start again at close to 12 please and please then talk to anyone
01:29:44 please then talk to anyone about your evidence when you're out of the room all right thank you very much
01:29:55 thank you across the 12th thank you
01:46:13 thank you would you ask us ready to come back in please
01:46:26 back in please right three yes i'm ready to carry on good yes mr miller yes mr chairman thank you i'm going to ask you some questions about the new aov system uh from january 2015. before i do can i
01:46:37 uh from january 2015. before i do can i just take a step back into some exchanges we had earlier this morning about uh the rge report can i ask you please to go to
01:46:52 max401426
01:46:56 now this is the record of significant findings and action plan uh from 20th of november 2012. you see that but it's been completed in the right hand column if you if you see
01:47:09 the right hand column if you if you see for the first item there fra reviewed april 2013 and outstanding actions raised you see that yes
01:47:17 that yes first do you know who it was who completed the review in april 2013. um i believe it was the low level reviews it was probably my colleague adrian bowman adrian bowman and did you supervise it
01:47:29 adrian bowman and did you supervise it did you see the fruits of his labor or did you just let him get on with it um i would have seen his findings yes right
01:47:37 right so you would have seen this document yes can we go to page seven
01:47:47 uh on page seven you can see there's a number 23c red high comment there are automatic opening vents on each flat lift lobby area it is not known if this system is
01:47:59 area it is not known if this system is serviced and maintained and then the recommendation from mr stokes can it be confirmed that the automatic opening vents on each flat stroke lift lobby area are serviced and maintained in accordance
01:48:10 serviced and maintained in accordance with the manufacturer's instructions and then ricky sams appears and then tmo have been informed vent needs changing resend quotes and reports and then this at the end
01:48:21 at the end reported since 2009 that rge cannot guarantee that in the event of an emergency this system will work reports sent additional copies to be
01:48:32 reports sent additional copies to be provided to to alex and then in caps completed what was that a reference to
01:48:40 um okay so this is sorry um so this is my when my colleague attended in 2013 to review april april 2013.
01:48:53 2013 to review april april 2013. um i i mean i haven't got any more information than what there is here um i think this seems to be reiterating the fact that we knew the system was old
01:49:05 the fact that we knew the system was old and would need replacing um no it's more than that isn't it it's telling you that there's been a report since 2009 and this is now april 2013.
01:49:16 since 2009 and this is now april 2013. it is yeah that rge with the maintenance contractors cannot guarantee that in the event of an emergency the system will work not that it was just old and needed replacing
01:49:26 replacing yes and therefore can we take it that even if you hadn't seen the august uh 9th 2011 uh report with the captain and the underlining and a bold message
01:49:38 underlining and a bold message nonetheless the message um in in that report is reflected in what i've just read to you in this column in in this document yes which would be why i was pushing them to replace it that's another reason
01:49:50 them to replace it that's another reason why we
01:49:50 why we needed to get on and do right um so can we take it that from april 2013 you knew that the aav system at grainfeld
01:50:01 that the aav system at grainfeld grenfell tower would not work in the event of an emergency
01:50:06 emergency i don't think it could be relied on to work in the event of emergency but i don't
01:50:09 don't think i would say that it would not work all right you knew that there was no guarantee that in the event of an emergency it would work because that's what the information seems to say yes and nonetheless can we
01:50:21 seems to say yes and nonetheless can we take it all say that in notwithstanding that message which you can be taken as having seen in april 2013 you yourself took no steps to put in place any infrared measures to
01:50:32 to put in place any infrared measures to mitigate
01:50:33 mitigate the risk indicated by those words there i myself know that i believe the owners would have been on the contracts management team
01:50:44 the contracts management team as their kit it's their kit that can't be relied upon and they're that they've got the expertise to identify what should which should or could be put in place to supplement or prop up or enhance
01:50:56 supplement or prop up or enhance or replace but was the onus not on you as the competent person for the purposes of the rro and the effectively seen effectively senior most operational
01:51:08 senior most operational manager in charge of health and safety across the tma stock to make sure that effective interim measures were put in place in order to mitigate the risk presented by this defect i think it's
01:51:19 presented by this defect i think it's for
01:51:19 for me to ensure that people are aware of their responsibilities in their area of control and to remind them
01:51:27 them and to reiterate um and to escalate but i can't ensure that it's done that's the
01:51:34 the problem i i can't ensure that it's done i can keep on being their guilty conscience and and cajoling and hassling and reminding um but i'm not in a position to make sure that it's done
01:51:45 sure that it's done because i don't have that relationship i don't have access to contractors that sits under contracts management team it's it's their responsibility i think that's quite clear in our health and
01:51:56 that's quite clear in our health and safety policy statement that that's their obligation in relation to this this type of care but isn't that really just a way of shifting the blame i mean you could couldn't you gone to your line manager uh or or insisted the online manager go to
01:52:09 or or insisted the online manager go to their line manager or brought it to the attention of the chief executive so that mr black
01:52:12 mr black could have wielded his supreme power and come down hard on the contracts team but the the minutes of all of the various meetings reflect that this is an issue
01:52:23 meetings reflect that this is an issue and this needs resolving so i am escalating it what my point is that i don't have control um and it it wasn't my role to have control it's it's my role to make sure people
01:52:35 it's it's my role to make sure people are clear of their responsibilities and to reiterate and to cajole and to explain
01:52:40 explain um and to escalate but i can't control that
01:52:44 that but you've been back if you're banging your head against a brick wall don't just carry on do you no because i'm escalating it aren't i i mean i'm escalating it every time there's an
01:52:55 i'm escalating it every time there's an opportunity and i'm having one-to-ones with the heads of
01:52:59 heads of um ricky sam's predecessor and his successor
01:53:02 successor um and i still can't ensure it now i understand that my question is a different one i'll put it one more time
01:53:10 time was there any reason why you couldn't have gone directly to robert black and say
01:53:13 say something's going wrong they're not performing i i need someone with more power than me to make sure they do um there was no reason i couldn't have done that
01:53:24 done that but i believe that i would have escalated it to peter at least peter madison's level he's in charge of all of the technical um uh staff
01:53:35 um uh staff obligations responsibilities now let's look at the new aav system in january 2015 tmo what tmo double zero eight four six seven three one
01:53:51 uh this is uh an email uh which claire williams is sending uh to you
01:54:02 as you can see on the 5th of january 2015 in which he forwards to you a an email from the gtla dated the 2nd of january 2015. you see that yes
01:54:14 that yes and if we go to the top of page 2 we can see the title of the email improvement work on existing smoke extraction and
01:54:25 existing smoke extraction and ventilation system which links to the fire alarm under the grenfell regeneration project but if we go back to page one i'm sorry to jump around we can see that uh claire williams says
01:54:36 we can see that uh claire williams says to you in her email to you please be aware peter m is drafting a response and i'm just confirming ryden's program for these works
01:54:44 works uh now by this time you were aware i'm assuming that gtla had al already raised in the past concerns about the aav at grenfell
01:54:53 grenfell so yes and did so indeed in 2012 yes yes and in fact possibly also in 2010 yes
01:55:01 2010 yes um because of the fire in on the 30th of april 2010 which we looked at yes i just can't recall the date but yeah yeah yeah so we've had two there have been two fires uh and two occasions for that now the
01:55:12 uh and two occasions for that now the nfb had issued a deficiency notice relating to the aov in march 2014 yes yes
01:55:17 yes yes and the existing aov system was quote not working and the new system hadn't been installed by january 2015. yes yes what information if any did you
01:55:28 yes yes what information if any did you think that the gtla should have had about the state of the aov in response to the their their questions well they should have had a truthful response shouldn't they yes now would you take it from me that
01:55:39 yes now would you take it from me that there were no updates um or no further updates minuted in any of the meetings with the lfb to the effect that the existing aov system was not operational take it from me that that is
01:55:51 operational take it from me that that is the case
01:55:52 the case are you able to explain why it was that the lfb were not updated about the state of the aov in the first part of 2015. no i'm not i'm aware that what i was being advised by
01:56:03 being advised by um claire williams and the project team that they were having regular discussions with the operational crews who were doing familiarization who who would be the people he obviously attended in the event of a fire and
01:56:15 attended in the event of a fire and i um and the team were aware of the need to keep the brigade updated and the need for interim measures and all things that we've discussed um so i can't give you any explanation
01:56:26 um so i can't give you any explanation we should have also included that information in progress meetings
01:56:32 yes now let's go then to carl stokes's fra for april 2016 and let's look at the uh we will in a moment look at the
01:56:43 the uh we will in a moment look at the uh
01:56:45 uh i'm sorry the significant findings and action plan related to that fra before we do can we go please to your first statement at page 21. let's
01:56:56 your first statement at page 21. let's look together at paragraph 90 and 91. you say there at 90. the aov system was assessed by cold stokes as recently as 20th june 2016 with carl observing that a notification of fire stated efficiency
01:57:07 of fire stated efficiency had been issued which required that a maintenance schedule be put in place to ensure that the new aov system is maintained and kept in good working order and then 91 karl incorporated this recommendation
01:57:18 karl incorporated this recommendation into the record of significant findings and action plan that he produced for us on 26th of april 2016 which you exhibit specifically he recommended weekly occupier inspections of the ventilation
01:57:29 occupier inspections of the ventilation system
01:57:30 system with the results recorded neither of these two documents contained any suggestion by carl stokes that the aav system was of inadequacy of non-compliance
01:57:41 now if we look at the 26th of april 2016 update
01:57:45 update to his fra significant findings and action plan let's have a look at that that's at cst 403098
01:58:03 we can see there's the date 26th of april 2016 on page one if we go to page five um you'll see item 19b
01:58:14 um you'll see item 19b towards the foot of your screen read high
01:58:17 high there are no operating instructions or has installed diagrams located next to the automatic opening vents aov control panel how is this control panel accessed and then actions to be taken
01:58:28 accessed and then actions to be taken provide operating instructions and has installed diagrams located next to the av control panel along with access information um and then there's more 19c it is not known if training on the operating
01:58:39 operating of the aov system has been given to all tma staff who requires it and there's a recommendation on that over the page 19e there's an aov we'll just expand that a bit please
01:58:51 we'll just expand that a bit please thank you there's an aov in the area or outside of the ground floor electrical room how is this aov activated as there is no smoke detector in this area 19f
01:59:03 19f you can see that are the aov system and installed fire alarm systems in this building remotely monitored and there are recommendations about that and then if you turn to the next page uh page seven
01:59:17 i'm sorry page uh uh eight i'm sorry my fault page eight 23 g read high all the weekly occupiers test the building's automatic smoke
01:59:28 the building's automatic smoke ventilation system being undertaken with a recommendation that they should be undertaken weekly with the results recorded as proof of the inspections having been undertaken now all of those systems i've read to you are high priority red risks aren't
01:59:40 you are high priority red risks aren't they
01:59:40 they yes um if we look at i'll just go back to page five first 19b let's look at that which i've read to you
01:59:50 at the foot there and then 19d on page six which i put to you um those were repeated in the june 2016 fra actions i i do you remember that all can i yeah
02:00:02 i i do you remember that all can i yeah and this one yes uh and we can see the recommendations in respect of 19b instructions should be located next to the aov panel that's page five we can just if we
02:00:13 panel that's page five we can just if we can just go back to that now focusing on that just let's just focus on it if you go to your statement of the 21st of august 2020
02:00:25 of august 2020 at tm00873934
02:00:31 go to paragraph 27
02:00:42 which is on page 16.
02:00:46 and you say there in respect of
02:00:53 fra item 19a that's the june reference which corresponds to item 19b in the april 2016 plan this item was assigned to myself the action taken column of the reference
02:01:04 action taken column of the reference tracking spreadsheet records written instructions provided diagram within hub room on site hub room accessed via key stored in key safe installed in bin room accessed via fb14 key
02:01:16 accessed via fb14 key can you can you explain what it was that was provided in the hub room i don't think i can other than what it says here because this would have been allocated initially to claire but there was quite
02:01:29 initially to claire but there was quite a volume of things so we would have sat down and anything that she could confidently confirm was in place
02:01:36 in place i took as much information from her so she could
02:01:39 she could go ahead and escalate the other the other issues which were outstanding and my understanding would be that it would be to comply with the requirement so that i would imagine there would be his own diagram
02:01:50 his own diagram and some written instructions um in the hub room and there'd been discussions i believe with the fire brigade about how they would access the key for the for the hub room well did you ensure
02:02:03 well did you ensure that there were instructions provided next to the panel as mr stakes had recommended um no i claire insured and i then just entered the the update
02:02:14 and i then just entered the the update so i didn't personally go there and check but she did that's my understanding so i don't understand when you say in your statement this item was assigned to myself what does that mean it it was a sign okay so as you said
02:02:26 it it was a sign okay so as you said there's
02:02:26 there's quite a lot of information being sought mostly
02:02:30 mostly it's coming to the end of ryden's contract so we're trying to get as much information in order to to complete these as possible so it was assigned to me because when it came in claire and i went through
02:02:42 came in claire and i went through all of the actions and identified what she still needed information from writings or planning or building control or whatever and then some that she was confident that she could resolve quite quickly um
02:02:55 that she could resolve quite quickly um she went away and did that i allocated to me and i closed it down so she didn't have to do the administration of it but i would only have closed it down when she confirmed that it was in place can you just help me why did you decide
02:03:07 can you just help me why did you decide to ignore mr stakes's advice and locate the plans in the hub room rather than next to the control panel uh no actually i can't help you sorry i have no idea
02:03:19 have no idea did you tell the lfb local crews or the lfb
02:03:23 lfb fire safety team where the instructions and keys were my uh my understanding is that the project team told the local
02:03:35 that the project team told the local crews
02:03:36 crews and um the local station manager because it would be them who would need that information and and then also i know there were briefings with said crews um around this time or maybe slightly later where they had the opportunity
02:03:48 later where they had the opportunity to be shown this aspect of what we had done
02:03:52 done and to raise any questions or challenges
02:04:03 now if we go to tma10033004 we can see an email from dave hughes of ryden
02:04:16 from dave hughes of ryden at the top there on the 5th of july to claire williams hi claire copy of simple guide to aov system as requested you see that
02:04:27 as requested you see that yes uh and if we let's go to the uh the attachment it's a tmo one double zero three three zero zero five this is the attachment if you um look at
02:04:38 this is the attachment if you um look at it it's called grenfell's tower smoke extract
02:04:41 extract system basic how to use guide when activated
02:04:44 activated did you see this guide at the time possibly
02:04:48 possibly possibly did you take any steps to make sure that it was accessible to fire crews attending the tower in the event of a fire well as as i've just stated
02:04:59 well as as i've just stated it was my understanding that the project team
02:05:02 team claire and ryden's in a regular dialogue with the operational crews covered this showed them where it was and then when they when ridings did a familiarization this would have been definitely on their
02:05:13 would have been definitely on their radar
02:05:14 radar did you take any steps to make sure that the lfb crews whether they were local crews or the fire safety team read this document
02:05:21 document understood it and judged whether it was sufficient for their purposes no not specifically but as you know we were having regular dialogue and the station manager was still coming to the liaison meeting so
02:05:32 liaison meeting so any concerns and grandfather was a standing item any any concerns any issues there was plenty of opportunity to raise them
02:05:41 do you know where this document was placed within the building well it says the hub room so that's my understanding this document went into the hub room i i know what i was told i didn't
02:05:53 i i know what i was told i didn't go and look at it firsthand um so that's my understanding can we go to one four tm00831144 please
02:06:04 this is a full mechanical operation and maintenance manual o m yep provided by j s
02:06:14 wright uh that that's page one of uh what is a very long document indeed comprising lots of different uh documents within it have you seen it
02:06:26 uh documents within it have you seen it before no
02:06:27 before no you've never seen this document no i don't believe so can we take it that you didn't provide this manual to the lfb yourself no i i really don't think i've ever seen it so no i didn't do you know whether it was
02:06:38 didn't do you know whether it was provided to allied protection who were the maintenance contractor for the aov come 2016. again i wouldn't i wouldn't know that that would be between claire and alex and i wouldn't necessarily be
02:06:49 and i wouldn't necessarily be party to any right can you tell us whether it would have been accessible to tmo
02:06:54 tmo employees um if i think any any employees who who would have needed it would have gone to clara to alex um and asked the question but i i don't
02:07:05 um and asked the question but i i don't know i don't know where it would have been stored sorry i i don't i really don't think i've ever seen it before right now let's move to october 2016. can we go to cst403137 please
02:07:24 this is a letter dated 19th of october 2016 from carl stokes to you subject is grenfell tower and he starts by saying thank you for asking me to inspect this building
02:07:36 asking me to inspect this building before an audit of the premises is undertaken by the london fire brigade under the rro next week i visited the building yesterday and as a result of my visit i would recommend that the following items are
02:07:48 recommend that the following items are addressed or information obtained to assist the london fire brigade inspecting officer when he refers to his 20 june uh 2016 fra so is it right that you had
02:07:59 2016 fra so is it right that you had asked mr stokes to visit grenfell tower ahead of an audit to be undertaken by the lfb i must have done yes why was that and the reason i asked why is that he'd only completed his fra
02:08:11 completed his fra uh four months before that on the 20th of june i think i think it was something that i've been instructed to do by peter madison several years prior that
02:08:21 that where we're having buildings audited that we we really should do our own checks in the first instance and so i think that's why i did it i see was that a was it a standing practice then of the tmo that whenever there was
02:08:32 then of the tmo that whenever there was an audit
02:08:34 an audit of a building in your stock you would send in carl stakes beforehand to pick up any potential deficiencies no because because generally we didn't know in advance um it was just that's what i'd been
02:08:46 it was just that's what i'd been instructed to do that where we knew in advance that was going to be audited by anybody
02:08:50 anybody that we should we should do our own checks um
02:08:54 checks um but as i say it was rare for us to know in advance that they were visiting and if they were sometimes i would just meet them on site and and if it was imminent then i would wouldn't obviously go to this extent we wouldn't stall
02:09:05 go to this extent we wouldn't stall their visit in order to do this it was just that where it was some time hence i'd been instructed that that's what i needed to do were you specifically instructed by anybody to instruct carl stokes in turn to visit
02:09:16 to instruct carl stokes in turn to visit grenfell tower on this occasion not on this occasion just as a general rule right and you say it was peter madison who issued that general rule was it or was it
02:09:25 was it it was some time previously um i think shortly after pete i think we spoke about this it was shortly after peter just started and i had provided a copy of a fire risk assessment with
02:09:36 copy of a fire risk assessment with information about unserviced extinguishers and and um he felt it was important for us to to do our own checks before we we issued uh documentation i think that
02:09:47 we issued uh documentation i think that was february 2013. you get my opinion yes okay um now if we go
02:09:52 go to page 11 please we can see that he refers
02:09:56 refers to some items from his june 2016. findings that were still outstanding and this is in the middle of that list you see but at 23g
02:10:08 he asks identified risk or hazard are the weekly occupiers tests of the building's automatic smoke ventilation system being undertaken you see that yes uh would you agree that
02:10:22 you see that yes uh would you agree that he had been recommending weekly checks of the aov since his
02:10:26 since his fire risk assessment in april 2016. we looked at that earlier yeah 23g agreeing yes so and it was something also recommended in his 20th of june 2016 fra again as item 23g
02:10:39 2016 fra again as item 23g yes it was a recurring item there so is it right then for us to conclude that these checks hadn't been implemented despite mr stokes raising them twice in two separate fras as action
02:10:51 twice in two separate fras as action items
02:10:52 items that seemed well seems to be the case sometimes um sometimes carl words things um where
02:11:03 sometimes carl words things um where he's looking for confirmation that they're in place it isn't saying they're not in place but can it be confirmed just it's just the way he word things words things so but it it does appear to still be outstanding um or
02:11:15 appear to still be outstanding um or he's still asking for confirmation whether they're in place in any case to be fair to you that there is a little bit of prior history to this i'll show it to you can we go to three nine tm0087393 four
02:11:27 uh and go to page eleven uh this is your august twenty twenty witness statement okay um
02:11:34 okay um where you've set out very helpfully in grid form
02:11:38 grid form um the the item in the significant finding schedule uh for june 20 um 16 if you go to line 23g you could see that
02:11:50 if you go to line 23g you could see that you set out there um weekly occupy inspections in the right hand column weekly occupy inspections of the building's smoke ventilation system should be undertaken with the results recorded of proof of
02:12:01 with the results recorded of proof of the inspections having been undertaken sorry that's the recommendation i'm sorry and then if we go to page 31 of your statement on page 17
02:12:13 you can see your reply there in respect to 23g okay uh you say paragraph 31 in respect for
02:12:24 uh you say paragraph 31 in respect for item 23
02:12:25 item 23 g this item was assigned to nicola bartholomew i noted been added to the action column which stated can you confirm that paul is undertaking these please
02:12:33 please in the action taken column it's recorded tested weekly on fridays yeah this action was fully completed by 13th march 2017. in a subsequent fra tracker a further
02:12:44 in a subsequent fra tracker a further comment has been added tested weekly on friday's inspection record supplied and then you attach a document which is the wt record confirming that now i've shown you to
02:12:55 confirming that now i've shown you to you in your statement because you've very helpfully brought all all the history together there just looking at what you say in paragraph 31 what do you mean by fully completed you say this action was fully completed
02:13:07 you say this action was fully completed by 13th of march 2017. what did you mean by fully it must have been fully completed on the w-2 system at that point in time um which is a significant delay um
02:13:21 yeah that's usually what i mean is it's fully completed on the w-2 system up until that point it was either outstanding or partially completed on the 13th of march was that the date when you were told about
02:13:32 when you were told about completion or the date which is which which the
02:13:36 which the fw2 system shows as the completion date it it must be the the date that the w2 system shows as completion but so it would have been completed and
02:13:48 but so it would have been completed and then sent back to our inbox but it we would usually be really prompt at closing them down so it's usually a fairly good reflection of when i've been advised that it's been completed
02:13:57 completed do you know when nicola bartholomew instructed paul stedman who is the esa to carry out these checks i don't i'm sorry um right
02:14:08 i don't i'm sorry um right it may be that there was a training aspect um
02:14:11 aspect um that he wanted to be more confident about specifically what he was he was what what the checking entails although i anticipate that it was largely visual but i i don't know i'm
02:14:23 but i i don't know i'm sort of speculating um can we assume from what we've seen so far that because carl stakes had raised this question again in his letter of the 19th of october 2016 at least by that date these weekly checks have not
02:14:36 that date these weekly checks have not yet been
02:14:37 yet been been implemented that seems to be the case judging by this yes can you explain why that is so no i can't as i um as i've said there may have been a training aspect where paul
02:14:48 have been a training aspect where paul may have
02:14:49 may have sought or required additional training um
02:14:52 um but again that would be something that could normally be put in place quite swiftly
02:14:56 swiftly and so i can't give any explanation are you able to tell us when it was that paul stedman did start to test the aov system weekly uh no they should be on his regular checks so it should there should be a did you
02:15:08 it should there should be a did you yourself ever check that he was testing the aav system weekly
02:15:13 weekly um i must have i must have been in dialogue with nicola
02:15:21 and nicola worked on site and and at that stage supervised paul so i was confident that what she said was accurate
02:15:28 accurate right but it was your responsibility to make sure supervising nicola bartholomew that these weekly checks were being carried out whether by paul stedman or anybody else on site yes but he's managed by he's not managed
02:15:40 yes but he's managed by he's not managed by me he's managed by people who are on site and can can speak to him can can supervise what he's doing given that this was an fra item for which you've had responsibility and given your role as a competent person do you you accept that it was your responsibility
02:15:52 accept that it was your responsibility to check that weekly uh weekly inspections were being carried out on site i i don't accept that i can supervise every single action at the completion of every single action on site because i
02:16:03 every single action on site because i just wouldn't have had the capacity to do that
02:16:06 do that um there were the people who were actioning these were often managed by very competent people and to some extent i had to rely on what i was being told not not across the board but i just i
02:16:18 not not across the board but i just i wouldn't have had capacity to check every single on-site action going back to the question of trying to date when it was that weekly inspections did start can we go to
02:16:30 met3065673
02:16:35 this is a a a report i think called the state service monthly checks at grenfell tower 16th november 2016 note defects period
02:16:46 16th november 2016 note defects period runs out until fourth july 2017. um is this uh document familiar to you no
02:16:52 no not at all not at all can you tell us what it is it's a document that was produced by paul stedman as part of his police statement you've not seen it before sorry no i've never seen it before i have no idea what it is
02:17:04 seen it before i have no idea what it is right do you know who would who did draft this document or who would ordinarily have drafted it um if it obviously relates to
02:17:15 um if it obviously relates to works that were undertaken as part of the major works so i don't know if it's something
02:17:19 something that claire williams or claire williams in association with ryden's i i'm i would assume it was one or other of that because it
02:17:30 it was one or other of that because it seems quite specific doesn't it now we've looked at this document and it does not appear to us to cover the testing the environmental function of the aov now was that
02:17:42 function of the aov now was that something that you were aware needed to be carried out testing of the environmental function of the aov
02:17:48 the aov i can't actually recall i remember that at the conclusion of the work there was quite a significant amount of checking that needed to be done at varying frequencies and which claire produced
02:17:59 produced and um my understanding was that training
02:18:02 training and um had been put in place some of it was going to be undertaken by contractors and some by staff i didn't really delve into the detail because between the estate services
02:18:13 because between the estate services teams
02:18:14 teams and claire and ryden's and contract management my understanding was it was in
02:18:19 in in place but um yeah sorry if we go to page six we can see at the top of page six that it says weekly
02:18:29 weekly the tmo need to check that the smoke ventilation system is working this entails ringing tunstall does this tell us uh even approximately the date when weekly
02:18:40 even approximately the date when weekly testing of the aov started or at least should have started it it should have started when it was commissioned and handed over um but there may have been a delay in terms of
02:18:50 of training but then it should it should have started um does does this document give us a date when
02:18:58 date when when we can be reasonably sure that it had not yet started sorry i don't know i don't know can we go to see it all right can we go to cst 6068 please
02:19:09 can we go to cst 6068 please this is the document we've looked at before
02:19:13 uh this is the weekly health and safety checks spreadsheet for grenfell tower but we'll need the the native version of it
02:19:31 we saw this last week mr ray but if we go
02:19:35 go to cell b6
02:19:38 you can see that there are weekly esa checks between the 1st of january 2016 and the 14th of june 2016. now we don't see anything there for
02:19:49 now we don't see anything there for the weekly tests of the aov do you know what uh if you look across we can't see that do you know how paul stedward would be expected to document his findings of the weekly aov
02:20:00 document his findings of the weekly aov testing at grenfell if it wasn't included on this on the spreadsheet i don't um
02:20:08 the sensible thing would have been to add it to the spreadsheet and no i don't i mean i think if nicola was still his his manager um i feel sure that she
02:20:20 his manager um i feel sure that she she could have liaised with the i.t teams in order to have it added but um i i don't i mean she clearly was ensuring that it was happening um so that there must have been some way of
02:20:32 so that there must have been some way of checking on on whether how paul was recording it but i don't know what that is i wasn't parted to the discussion sorry are you a do you know what training was given to paul stedman uh in relation to the aov system um
02:20:45 uh in relation to the aov system um that would really be a question for claire um ryden's did provide familiarization and i think then subsequent additional training if it was required but i don't have the detail of it what about seamus dunlee the handyman
02:20:57 what about seamus dunlee the handyman did he ever get any training on the aov system at grenfell tower even generically i would have thought similar to paul really now let's look at a slightly
02:21:08 really now let's look at a slightly different topic which is the the inspection and maintenance of the new aov itself
02:21:15 dr lane has summarized her opinion about the inspection and maintenance requirements applicable to the new aav in chapter 7 of her of her report uh uh
02:21:27 of her report uh uh and i think i can summarize it quickly by reference paragraph if 5.9.109 blarp two
02:21:38 blarp two five zeroes 33 page one zero six she says that the minimum maintenance steps include weekly monthly quarterly six monthly and annual inspections
02:21:50 inspections um do you agree with that um i'm sure she's better qualified than me to to comment i wouldn't know that off the top of my head i could find out pretty easily but i'm not an engineer
02:21:59 engineer all right now um take it from me that the completion certificate for the new aav system was dated third of may 2016 and we make that good by reference to it to the document tmom
02:22:10 to the document tmom four zeros one eight six two nine should turn it up are you able to explain what the maintenance regime was that was put in place for the new aov i'm not you're not um my understanding
02:22:23 i'm not you're not um my understanding was they would still be under defects for at least 12 or 12 months period um and therefore i would have expected any of the more technical inspections and servicing and maintenance visits to be undertaken
02:22:34 be undertaken so my expectation would be that the quarterly six monthly the annual all of those would be done by possibly js wright if they were the appropriate contractor um we've already identified that the
02:22:46 um we've already identified that the assessor is also asking for weekly inspections and i believe that the monthly would also have been done by the estate staff but i
02:22:54 but i i couldn't definitively say now the first inspection we've got on record or servicing we've got on record by allied protection relating to the new aov system was carried out on the 17th of january 2017.
02:23:08 carried out on the 17th of january 2017. uh that's eight months after it was installed
02:23:11 installed there's a reference to that which is lak seven zeros nine there's need to turn that up are you able to explain why there was such a significant gap in the contractors inspection or
02:23:22 the contractors inspection or maintenance visits no i'm sorry i'm not and i'm i wouldn't i wasn't even aware of that until you you just
02:23:28 you just advised and it would have been so the contract team were managing the project at the end of the project any plant maintenance that has to transfer immediately over they would have to go via the contract management team so there would have been
02:23:40 management team so there would have been discussions between those teams without me being party to them um can you explain why you weren't party to them
02:23:47 to them given that you were the competent person and was always the competent person for grenfell under the rro why wasn't that the the continuing maintenance and inspection regime for the aov
02:23:57 the aov passed to you upon completion so that you could take charge of it because we have a dedicated team doing plan preventative maintenance and that's
02:24:08 plan preventative maintenance and that's their core job and what they do you're right i've got i've got oversight ideally
02:24:13 ideally um but i but i couldn't be responsible for taking forward the maintenance and we have a team a dedicated team who are doing that and we have a team who know exactly what they've installed and have all the o m and all of the records it seems
02:24:25 m and all of the records it seems logical for them to pass the information over and for them to have dialogue
02:24:30 i think i think if if i had a bigger team then i would have more of an input into that but i trusted them to discuss with each other and put in place what was appropriate
02:24:41 in place what was appropriate yes i see that but my question is slightly different if given that you were the competent person and held effectively ultimate responsibility operationally for health and safety over
02:24:53 operationally for health and safety over the tma
02:24:54 the tma stock can you explain how you were not aware
02:24:58 aware that there was an eight-month gap between installation and the and what appears to be the first in recorded inspection or servicing of the aov system i can't not without going back to colleagues
02:25:09 colleagues in contract management because as i say that was their dedicated role to manage those contracts manage those contractors make sure they performed ensure that remedial works are put in place as and when required
02:25:20 place as and when required put in place interim measures i was having regular dialogue regular meetings with alex it was not brought to my attention um and i
02:25:31 um and i did not have enough time to go delving into their service records now i understand why you might not have had time to look at the granular detail of the service records themselves but surely
02:25:40 surely you you either did have time or should have made time simply to ask the question
02:25:45 question there's a new aov i know went in at grenfell
02:25:48 grenfell eight months it's been some time has it been maintained did you ask that question i can't remember asking that question but i did um i was confident that the the
02:26:00 i was confident that the the responsibility and had been passed across to the appropriate people and they knew what their role was and if they needed any further information they had access to the special contractors the design bill contract
02:26:12 contractors the design bill contract the contracts manager um so to the best of my knowledge all of those processes and all of that dialogue was taking place i wasn't party to to
02:26:23 i wasn't party to to the detail of it but to the best of my knowledge that was what is in place as you say everybody knew that a new aov system had been installed and the contracts management team had had some dialogue with the contracts
02:26:34 had some dialogue with the contracts team
02:26:35 team knew that the project was coming to an end and knew that must have been preparing
02:26:38 preparing i thought to take over that particular responsibility and make sure that their contractors were also geared up for it it would have had to be added to contracts there would have been all sorts of things that would have been needed to be put in
02:26:49 that would have been needed to be put in place and it was my understanding that they were being put in place what gave you to understand that somebody tell you that these very regular inspections were happening or did you just make that
02:27:00 happening or did you just make that assumption without asking the question
02:27:04 i met with the head of contracts management on a i think maybe a two or three weekly basis um there might have been quite a wide ranging
02:27:13 ranging agenda there might have been 20 different things that we were speaking about but there were always opportunities to discuss any issues any contractor issues anything that was outstanding anything that had to be brought to my attention
02:27:24 that had to be brought to my attention um
02:27:25 um equally if i had had anecdotal comments about performance of contractors that was my opportunity so we had quite full and frank discussions um i can't remember specifically asking the question that you've put to me
02:27:37 the question that you've put to me but
02:27:41 i shouldn't have needed to that may be but it's a question of responsibility and i'm just trying to identify whether it was you who was responsible ultimately for making sure that these regular maintenance and inspection
02:27:55 these regular maintenance and inspection and servicing took place i don't think it was
02:27:59 it was who's was it there i mean i think it's clear
02:28:02 clear from our health and safety policy statement that the contracts management team
02:28:06 team manage monitor the um systems that we have in place procure the contractors ensure they get competent advice to ensure that the levels of checking are exactly what they should be all of
02:28:18 are exactly what they should be all of that sits with that team i i have dialogue with them and in an ideal world i would have done more delving down into the granular detail
02:28:29 detail but they were competent to do that role and that should have been their role but i'm just trying to understand this because
02:28:37 because the contracts management team as you say manager and monitor the contracts but you're in charge of health and safety so it wasn't your responsibility to manage supervise
02:28:49 your responsibility to manage supervise and monitor the contracts team so is to make sure
02:28:53 make sure that whatever it was that the contracts team were doing they produced the goods in terms of compliance with the rro
02:29:04 there's about six people in the contracts team all managing very specific
02:29:08 specific contracts the contracts team is also building up um kpis uh sits on the health and safety committee where they also report into so lots of opportunities not just for me
02:29:21 so lots of opportunities not just for me to meet with the head of on a regular basis but for them to raise issues for them to feedback on performance of contractors i i i don't think you can take away their responsibility
02:29:32 their responsibility i think i think sorry i'm not trying to i'm not suggesting that they're not responsible what i'm trying to get to the bottom of is how you saw your responsibility
02:29:44 responsibility uh in relation to theirs my responsibility was to keep a degree of oversight of what they were doing be aware of where they were
02:29:55 doing be aware of where they were where they were interim measures where they were failing contractors what we were doing to mitigate risks um what's coming along on the highway any areas of non-compliance
02:30:06 non-compliance how are we addressing those how are we getting on with kpis when are we going to have fire safety kpis what have we got on keystone who's got access to all of all of that which which is why i would meet
02:30:17 would meet with um the head of contracts management and they sat on the health and safety committee
02:30:23 committee um and before that there was the operations group there were lots of opportunities for dialogue so that i could start to get the detail of what i needed but it's a it's a big amount of
02:30:35 but it's a it's a big amount of work sorry it's a big remit and within that i was trying to focus on the things that
02:30:41 that that um i thought were the most important
02:30:46 important so it was a question ultimately you're prioritizing things you thought were the most important in exercising the degree of oversight that you had to
02:30:57 the degree of oversight that you had to some degree it had to be because it was a finite amount of time and a vast amount of work so that was i was trying to to make the two marry up yes i see well in light of that helpful explanation
02:31:08 helpful explanation coming back to my question are you able to explain given the degree of oversight you had and
02:31:14 and the way you prioritized uh why it was that an
02:31:17 that an eight-month gap was allowed to open up between the installation of the aov system and its first recorded inspection or servicing in january 2017. and i have to give you
02:31:28 in january 2017. and i have to give you the same answer i don't know the answer to that but if you had the head of contracts management here he could probably tell you because there are probably a lot of other factors that neither you or i are aware of
02:31:38 of um that would contribute sorry well mr i think the only question mr millett's asking you to focus on is were you aware that there was the eight-month gap and if not why not yeah i appreciate that no i wasn't aware
02:31:50 yeah i appreciate that no i wasn't aware and
02:31:51 and i i can't really add anything more to the explanation i've tried obviously badly to put together that's right thank you now let's just finish off quickly on this i'll give you two dates um
02:32:02 this i'll give you two dates um the next service visit for the aov was out it was 13th of april 2017. that couldn't go ahead
02:32:08 ahead because paul stedman wasn't on site so the next service visit was the 15th of may 2017.
02:32:14 may 2017. dr lane has concluded that the frequency of inspections four months apart is substantially less than that required by the relevant british standards and that's paragraph nineteen point six point two four at blarp
02:32:27 point two four at blarp two three four five six zero thirty three page four six seven uh what steps if any to your knowledge did the tmo take to make sure that the aov
02:32:39 the tmo take to make sure that the aov system
02:32:40 system maintenance arrangements through external contractors was compliant with the british standards as applicable
02:32:48 again i can't answer that contracts managers
02:32:52 managers would be able to answer that comprehensively because they know who they sought advice from and what the information they received from the specialist contractors when they received it
02:33:03 when they received it what the o manuals they had access to all of that but i didn't so i i can't you able to tell us whether the tma put in any put in place any defined procedure for the maintenance of the new
02:33:15 procedure for the maintenance of the new aov system once it was installed i can't no
02:33:21 and you can't because is this the same reason as before it was managed by contracts management yes but not overseen by you not to that level of detail no not you
02:33:34 not to that level of detail no not you say that to that level of detail with great respect it's not a level of detail to put in place a policy or a procedure or a protocol for the maintenance of a new aav system in a large residential high-rise is it
02:33:46 in a large residential high-rise is it it's not a level of detail
02:33:50 it's a level of detail i would expect the contract manager to work with the contractor to agree exactly what they're doing when they're doing it agree a program agree the extent of the text that
02:34:01 agree the extent of the text that they're doing and when they're doing it it's not a level of detail that i would normally be involved with i'm not a contracts manager and i have you know some technical knowledge but but limited so it's not something that i
02:34:13 but limited so it's not something that i would
02:34:14 would feel it was it was for me to to lead on not for you to lead on but for you to over have any oversight on um in
02:34:29 i would expect it to happen and i would have
02:34:33 have liked to be involved in what was agreed but i wouldn't always be because it's not the only building and it's probably not the only bit of specialist kit lifts we can go to that next topic
02:34:45 lifts we can go to that next topic um can i start by getting into the question of the definitions mr a with about lift firefighting lifts uh and i want to look specifically at grenfell tower can we look at your
02:34:57 at grenfell tower can we look at your evidence
02:34:57 evidence uh on uh 9th of june this year last wednesday uh and i'll i'll summarize if i get this
02:35:08 and i'll i'll summarize if i get this wrong we can look at the transcript it's day 142 page 93 it lines 22 to 25 for our own references and you recall that i put carl stokes his letter of the 23rd of june 2010 to you cst401887
02:35:23 2010 to you cst401887 um and you said that it was a there was a point of dispute disagreement between mr stokes and you you said i i was very clear that they were not firefighting lifts or evacuation lifts and my discussion
02:35:36 or evacuation lifts and my discussion with my then senior lift engineer had clarified that you remember that evidence yes yes and you also clarified that robin uh callan uh was that lift engineer that's right
02:35:47 that's right yes uh and you also went on to say day 142 page 94 lines one to five that you say had that uh that had been con and that had been conveyed to salvas and
02:35:59 and that had been conveyed to salvas and was discussed with mr stokes but he was he remained utterly convinced that they were firefighting lifts and so insisted on still describing them in that way that was your evidence last week
02:36:10 was your evidence last week yes i'm drawing the threats together can we agree
02:36:14 we agree that carl stokes repeated in every fra he did for grenfell tower between 2010 and 2016 twice in 2016 but the two lifts at grenfell tower were fire fighting stroke evacuation lifts he
02:36:27 fire fighting stroke evacuation lifts he did he did and therefore that those lifts could be used for evacuating residents from that building in the event of a fire that's what he said but as i also said last week we were
02:36:39 but as i also said last week we were never going to use them in that way now do you agree also that in 2010 you and robin
02:36:44 and robin cahila the tmos fire lift engineer created the tma's own definition of a firefighting lift yeah i don't think we meant to create a definition we and salvas had asked
02:36:57 definition we and salvas had asked specific questions about the how what kind of lifts we had basically particularly above 18 meter blocks um and i met with robin and robin attended a progress meeting with salvos
02:37:08 attended a progress meeting with salvos and i think in discussion with salvers um they felt it would be helpful to to outline which of the criteria they did meet and and think that was all we were trying to do was was clarify
02:37:19 were trying to do was was clarify so it wasn't meant to be defining it was just meant to be saying okay oh lifts don't meet don't meet um the full requirements of firefighting evacuation lifts however they do meet x y and z
02:37:29 y and z yes let's let's go to that progress meeting then in light of that this is uh and if this is not the one tell me sal 6042 what i'm showing you is the minute
02:37:40 6042 what i'm showing you is the minute of a progress meeting for fire risk assessments in high-rise blocks high-rise blocks sorry high-risk blocks i'm sorry
02:37:49 i'm sorry um well they said i think they're the same yeah i think i meant um 23rd of february 2010 you see that yes and and we could see that you're there
02:37:59 there andrew finesse is there adrian bowman and also robin carlon yep for part of the meeting and and apologies from others including and much more
02:38:09 much more if we go to page one a little bit lower down you can see the subject of lifts is discussed
02:38:14 discussed and i'll just read it to you it says this um robin carlon tmo lift engineer attended for this item janus advised that a number of the fra action plans had raised specific queries in relation to lifts and these
02:38:25 queries in relation to lifts and these have been referred to robin who was seeking confirmation from salvas that his interpretation of what constitutes a firefighting lift is the same as theirs the specific points from the action plans were as follows
02:38:36 follows and then they're set out in the box there and then after that it says rc then outlined the three different classifications of lifts in terms of firefighter fire fireman's lift fire fighting lift
02:38:47 fire fireman's lift fire fighting lift and evacuation lift after some discussion the group concluded that most of the borough's lifts
02:38:52 lifts meet the majority but not all of the criteria which define a far fighting lift it was agreed that for the purposes of the action plans jw that's you and rc that's robin colon
02:39:04 that's you and rc that's robin colon would document the criteria that tmo lifts do meet rc clarified that the requirements for lifts below a certain size are less onerous
02:39:12 onerous and so these lifts are less likely to comply with a significant number of these criteria action rc and jw to document the criteria that the tmos
02:39:23 to document the criteria that the tmos firefighting lifts meet and advise salvas so that this can be included
02:39:28 included in future action plans
02:39:32 first can you explain what specific queries have been raised about the lifts in the fra action plans i think it's these three points that we've um is recommended these were coming up regularly um in the
02:39:45 these were coming up regularly um in the significant finances and action plans and we were trying to be clear about how they should be addressed right uh those are those are the
02:39:57 right uh those are those are the confirmations or rather the recommendations because they're the action points to be taken away what i'm really after is the the concerns that have given rise to them um
02:40:10 let's go to let's go to cst 50631 what i'm going to show you is the fra which carl stokes completed for grenfell tower of on the 30th of september
02:40:23 tower of on the 30th of september 2009 while he was still working at salvos there it is and if we go please to page 14 in that document you'll see item 9.3 we've seen it before a number of times with other witnesses lack of firefighting lifts installed in
02:40:35 lack of firefighting lifts installed in the building you see that yep and then it could not be confirmed at the time of the fire risk assessment if any of these lifts are fire fighting or evacuation lifts was that
02:40:46 fighting or evacuation lifts was that one of the specific queries yes right then if you go to the action on page 18 this is where we see the recommendation which is reflected in the box on the first page of the progress meeting
02:40:57 the first page of the progress meeting minute we've just been looking at it is recommended this is the action related to 9.3 first action
02:41:04 action it is recommended that tmo confirms if any of the lifts installed in the building are either firefighter or evacuation lifts and that had an amber color which meant that it's best practice or
02:41:15 meant that it's best practice or guidance
02:41:16 guidance yes yes so can we take it from september 2009
02:41:21 2009 you knew that grenfell tower lifts were not fire fighting lifts or at the very least it was not clear that they were um the sabbaths are asking the question and
02:41:33 the sabbaths are asking the question and the
02:41:33 the minutes that we've just discussed and the meeting that took place was me trying to clarify exactly what we had where
02:41:40 where and um that yeah so from certainly from february i knew that was the case yes were you um advised by anyone from salvas that the lifts at grenfell tower
02:41:52 the lifts at grenfell tower should have been fire fighting lifts no i don't recall her you don't no uh
02:42:01 can you explain the discussion that was had at this meeting about the lifts particularly the criteria that they did meet we can go back to the note if you like
02:42:14 i'm not sure i can add much to to the note i mean the the list of the criteria that we were confident that they didn't meet has been included in various policies and and
02:42:25 included in various policies and and whatever strategies um so i think we we robin outlined the main things that he was confident that they met he was very keen to point out that they didn't have a a hatch a reef hatch
02:42:38 they didn't have a a hatch a reef hatch in
02:42:38 in in the car um and obviously other other issues but i don't think we went into more detail really than what we died out loud outlined uh why was it decided that you and robin
02:42:50 why was it decided that you and robin collin would document the criteria that the lifts did meet um as i say in discussion with andrew finesse he seemed to think that that was that was a wise way of approaching it so
02:43:01 that was a wise way of approaching it so um
02:43:01 um i would have robin would have outlined them and i probably just would have been described
02:43:05 described but put them together what was the the goal here that you could avoid upgrading the lifts to firefighting lifts no it was to clarify um we were asked to confirm if they're if
02:43:17 we were asked to confirm if they're if what they are we're confirming what they are and we're trying to go a bit further and explain what that means can we go back to the note the meeting please at
02:43:25 please at sal 6042 page one towards the bottom of the page
02:43:35 you can see the action point yeah you describe the lifts as the tmos firefighting lifts don't you i always put it in speech marks when i
02:43:46 i always put it in speech marks when i so that it's quite clear that it's um that they're not firefighting left well you don't here do you the but at the foot of the page i'm looking at the action point ask the njw to document the criteria
02:43:57 ask the njw to document the criteria that the tma's firefighting lifts meet yeah not there but that follows on this is just the yeah no so not so not always but but my question isn't about punctuation why did you why did you use
02:44:10 punctuation why did you why did you use the expression firefighting lifts there at all why not say tmos lifts well that's what i should have said but what is it why didn't you there's a reason for that no no there's nothing sinister i just
02:44:21 no no there's nothing sinister i just have a lot of notes to do and i obviously didn't do those as meticulously as i should um there was there was no you know it was quite clear from the discussion i'm not
02:44:30 not trying to pretend that they were firefighting lists because it was always my
02:44:33 my understanding from this point in time that they they weren't right so can we can we then take it that you accept that that note's incorrect to the extent that it describes the lifts the lifts as firefighting lifts the action point is
02:44:45 firefighting lifts the action point is yes the action point now after this meeting do you remember you emailed andrew finesse with the information about the tmas lifts
02:44:54 lifts uh cst 403102 where we see the email
02:45:03 you remember you remember this email it's 3rd of march 2010 um yes i think so if we go to the foot of the page
02:45:10 the page uh which is where we see the email uh it's copied to among others adrian kalan
02:45:18 kalan andy further to the discussion at the recent progress meeting robert and i put together the following information which relates to tmo lift serving blocks over 18 meters in height one minimum car size and you set out the
02:45:29 one minimum car size and you set out the definition and over the page
02:45:35 uh andy robin's colleague is currently going through the asset register to identify the locations of these lifts two dedicated power supplies serving left three phase
02:45:47 left three phase etc
02:45:51 other things with dedicated power supply three two-way communication on new lifts includes connection to customer service center out of hours monitoring services lift
02:45:59 lift alarm is activated four fireman's control switch fitted you can see the rest of that text five lift car and landing doors are
02:46:10 five lift car and landing doors are composed of stainless steel that is not less than 16 swg thick and over two hours fire resistance you see that yes uh now um was it your intention to create with robin carl on the def
02:46:20 the def the tmo definition in-house definition private dictionary if you like of a firefighting lift no it wasn't uh it was our intention to try
02:46:32 it wasn't uh it was our intention to try and be
02:46:34 and be transparent about what criteria the lifts did meet while accepting that they didn't that they weren't firefighting or evacuation lifts
02:46:43 lifts we thought that we thought that might be helpful information for the fire brigade because i
02:46:47 because i subsequently sent this on to brian deans who was then the borough's fire commander
02:46:53 commander right so you've set out here uh all these
02:46:57 these features um but you don't anywhere conclude that notwithstanding all these features they are not to be taken as firefighting lifts because they are not
02:47:09 lifts because they are not do you this was an email to andrew ferness
02:47:12 ferness after the meeting where this was discussed at length he was quite sorry i thought my intro just said these are the features that our um our lifts do meet he was quite clear that they weren't it was
02:47:23 quite clear that they weren't it was explicit that they weren't yes and um i mean look at his response then
02:47:28 then let's make some more sense of what you've just told us in the top of page one he comes back to you the same day a couple of hours later hi janice thank you for the information we will
02:47:39 thank you for the information we will include the following statement in relation to firefighting lifts based upon the details attached and then he goes on to say tmo has confirmed
02:47:48 confirmed that lifts servicing the block over 80 meters in height meet the requirements for fire fighting lifts as per specification provided by tmo's senior lift engineer and then if you get out of the last paragraph
02:48:00 you get out of the last paragraph uh we will include these statements for all assessment reports for those blocks visited on or after 4th march 2010 and suggest that as you work through the action plan in relation to the previous fras that you include the statement to indicate closure
02:48:13 the statement to indicate closure thereby showing that tmo is actioning the findings of the fras thus complying with the requirements of the fire safety order now
02:48:23 i'll come back to that in a moment can i before i do show you what you say in your third witness statement at tm00847305 page 26
02:48:37 paragraph 91 however i never said to andrew that the tmo were confirming that the lifts in
02:48:49 tmo were confirming that the lifts in tmas buildings over 18 meters met all of the requirements of the regulations my intention was to point out the features of the legislation that the lifts did display complied with i was aware that the tmo lifts did not
02:49:01 i was aware that the tmo lifts did not meet all of the requirements now would you agree that your email went rather further than what you say there because the information that you provided
02:49:12 information that you provided to andrew furness was to be used in all future fire risk assessments and in previous fras just to represent that the lifts in buildings over 18
02:49:23 that the lifts in buildings over 18 meters in height were in fact fire fighting lifts i wouldn't accept that now but that is what he said in his response-y man isn't it
02:49:31 it well i can only reiterate he was at the meeting where it was discussed and he thought
02:49:36 thought it was probably his idea to set up the criteria that they did meet so he was absolutely clear that they weren't firefighting lifts or evacuation lifts um so there wasn't any ambiguity between us
02:49:50 so there wasn't any ambiguity between us well i i'm not suggesting there was any ambiguity between you at all ms ray what i'm putting to you is what you say paragraph 91 of your statement is is a gloss and that when you look at the
02:50:01 is a gloss and that when you look at the reply
02:50:01 reply that mr fenner sent back to you on the 3rd of january that year he says the tmo has confirmed that lift servicing the block over 80s in height meet the requirements of firefighting lifts as per the specification provided
02:50:14 lifts as per the specification provided by the tmo senior lift engineer so what i'm suggesting to you is that he is accepting the tmo's in-house definition of a firefighting lift no i don't i don't disagree because he
02:50:25 no i don't i don't disagree because he was a very competent fire risk assessor and he was he was involved in a lengthy discussion about this so he he was absolutely clear that they were
02:50:37 he was absolutely clear that they were not
02:50:38 not firefighting lifts well can we go back then
02:50:41 then just to examine word for word what he said in his email of response please this is the previous document i showed you which
02:50:48 you which is at cst403102 page one top of the page he says there second paragraph um
02:51:00 well first paragraph again we will include the following statement in relation to firefighting lifts based upon the details attached and the details attached to what you've sent him and this is the start of the statement
02:51:11 and this is the start of the statement he is saying we'll go into fras tmo has confirmed that lift servicing the block over 18 meters in height meet the requirements for firefighting lifts as per specification provided by
02:51:22 lifts as per specification provided by tmo
02:51:23 tmo senior lift engineer what he's doing is is telling you that he's going to state that the tmo has said that lift servicing the relevant block
02:51:34 servicing the relevant block meet the requirements for firefighting lifts as per the specification that's what he's saying and i'm putting to you
02:51:42 to you that that is to the extent that it suggests
02:51:46 suggests that firefighting that these lifts were fire fighting lifts uh is misleading isn't it because they weren't
02:51:57 there's there isn't really a disagreement here there they were not firefighting lifts he knew they were not firefighting lifts that is what based on our discussions and my email
02:52:08 and my email um that's what his decision was to to put into the fras right well i have to say sorry i'm puzzled about this because
02:52:17 because what um mr funny seems to be saying here is that he intends to include in fire risk assessments a statement to the effect that the tmo
02:52:28 a statement to the effect that the tmo had confirmed that they were that they met the requirements for firefighting lifts which is another way of saying they are firefighting lifts now if you thought that was wrong wasn't
02:52:40 if you thought that was wrong wasn't that the moment at which you should have gone back and said sorry there's a mistake here i think i went on and read as per the specification provided by the senior lift engineer well was that a specification that was different from
02:52:52 specification that was different from some published specification that one could refer to yeah yes it it's um what we just what we discussed just now
02:53:04 what we just what we discussed just now andrew in the in so in the meeting we robin kalan was very clear that we didn't have any firefighting evacuation lifts in the stock however he went on to say and i wish he
02:53:15 however he went on to say and i wish he never had now obviously um but actually our lifts in high-rise blocks
02:53:20 blocks met quite a significant number of the criteria and i believe it was andrew ferness who said well that would be helpful to outline that
02:53:27 that so so i think we've got tangled up in something that he instigated and then worded
02:53:36 but it looked like a recipe for confusion if you're going to uh effectively create your own definition of a firefighting lift which is then going to be used without qualification yeah and i mean that that was never the
02:53:48 yeah and i mean that that was never the intention and as i say when we wrote to the borough fire commander at the time um and normally i would always have made sure that i had exclamation mark you know that speech marks and whatever and reiterated
02:54:00 speech marks and whatever and reiterated that they don't meet these however they do have the following features but i can see that this is um
02:54:08 not greatly worded um but it's more yes just thank you mr chairman it's not more it's more than not greatly worded it is a chairman suggested a recipe for confusion because i'm suggesting to you what you're doing
02:54:19 i'm suggesting to you what you're doing here is is accepting uh or going along with the suggestion that you would call lyft's firefighting lifts not in accordance with established standards but in accordance with the tmos in-house definition
02:54:34 tmos in-house definition yeah yes
02:54:38 that wasn't the intention but that appears to be the way it went yeah now after this uh that was agreed um and carl stokes of course became the
02:54:49 and carl stokes of course became the selected tmo fire risk assessor later this year
02:54:53 this year at least for the medium risk program and then again for the low risk program in the following year you then gave carl stakes this information uh in the june of 2010 didn't you
02:55:04 didn't you um i gave him i think the copy of the email that i sent to andrew furness setting out um yes below yes i mean we don't perhaps need to look at it cst401887
02:55:15 cst401887 page two meeting of the 22nd of june referred to in his letter of the 23rd of june 2010 and he also repeated it in your meeting with him on the 24th of september 2010 as repeated in his letter back to you on
02:55:26 as repeated in his letter back to you on the 27th of september 2010. i mean we've been through all this last week um
02:55:32 week um perhaps we should just look at the last of those documents cst403061
02:55:40 this is his letter back to you at the 27th of september 2010 following your your meeting on the 24th of that month and if you go to page one there's the first page of the letter
02:55:51 first page of the letter um you could see that there is a long list on the first page of the items covered by the letter and halfway down just below halfway down the list is lift maintenance service and testing policy you see that there
02:56:02 testing policy you see that there yes now if you go to page three of the letter you can see where that's covered under the heading lift maintenance service uh servicing and testing policy
02:56:13 service uh servicing and testing policy in tma residential buildings towards the foot of page three and it says this the following information relates to firefighting and evacuation lifts in tma residential buildings over 18 meters in height copy of an email from mrs ray
02:56:24 of an email from mrs ray and then that there i know the page your email
02:56:28 email is copied and that that's really a lift from the third of march 2010 email we saw earlier yeah yes now uh you can we take it then that you
02:56:41 you can we take it then that you instructed carl stokes uh in preparation for his taking on the medium and then later the low risk program
02:56:49 program to include the same phrase in his fire risk assessments that you'd agreed with andrew furness um i i didn't instruct him to use the same and also the medium risk would be
02:57:00 same and also the medium risk would be generally the blocks under 18 meters which we had already established were had probably didn't even have this number of attributes so it didn't automatically follow that
02:57:11 so it didn't automatically follow that the blocks that he was going to be assessing met the same criteria in terms of
02:57:17 of of height
02:57:21 uh well we know what happened in the end because in fact he became the fr fire risk assessor for all the blocks of all risks in the estate but if you look at
02:57:31 look at um the list it goes over to page four of the letter and after the nine uh paragraph points uh in the first sentence there the text he says from the
02:57:42 sentence there the text he says from the information above the lifts where fitted in residential building would also be suitable to be used by disabled persons as a means of evacuating the premises and the tmo asset register system holds all the premises addressed et cetera et cetera
02:57:54 cetera so it's clear from that isn't it that you are proceeding with mr stokes in the same way that you had been proceeding as we saw with mr furnace
02:58:06 as we saw with mr furnace um in other words to treat the the the lifts in the tmao estate as far fighting lifts or evacuation lifts i am confident that i spoke to him repeatedly during the time he worked for
02:58:18 repeatedly during the time he worked for us
02:58:18 us on specifically this matter and i know there was a subsequent email from robin collin
02:58:23 collin which might have been 2011 where robin said
02:58:26 said um the quote you know the criteria have now become clearer and i'm just emailing to say we definitely do not have any firefighting or evacuation lifts and that was sent to carl and to myself
02:58:37 carl and to myself and carl came back even challenging that and saying well i'm not sure what standard you're referring to but i'm not aware of any changes so it's so there there was subsequent
02:58:48 so there there was subsequent communication where robin collins said just to be absolutely clear we don't have any and the cost of upgrade them would be prohibitive um and he had that as well
02:59:00 as well why did you not go back to him on receipt of this letter and say to him although the lifts have the features you have identified i have identified in my email which you have rightly lifted
02:59:11 lifted these should not be taken as firefighting or evacuation lifts because they are not i think it is likely that i did go back to him verbally
02:59:20 verbally i certainly did repeatedly over the years and i still got met with no i'm confident they are i'm confident they are right mr chairman we will we will be pursuing
02:59:31 mr chairman we will we will be pursuing that evidence after the break i think now it's a convenient moment yes all right thank you very much well it's a good time to have a break for some lunches right um we'll resume at two o'clock please and again please don't talk to anyone
02:59:43 and again please don't talk to anyone about your evidence while you're out of the room all right thank you very
02:59:54 much two o'clock then please thank you
03:00:11 two o'clock then please thank you you