TMO Health and Safety Manager questioned on fire risk assessment (FRA) management, priority ratings system failures, and inadequate deficiency notice tracking.
00:00:20 yes would you ask us ready to come back in please
00:00:24 in please all right
00:00:33 all right that's right ready to carry on yes very good thank you yes thank you mr chairman uh miss ray i want to ask you now about priority ratings for fra items a little bit more closely
00:00:45 for fra items a little bit more closely can i ask you please to be shown
00:00:49 tmo.00840881
00:00:56 this is the minute of the operational health and safety meeting of the 21st of march 2014 we can see that you're present can we go to page three please
00:01:07 and on page three uh you can see in the middle of the page below item 4 it says the risk allocation in the fra actions is as per the definition set out
00:01:18 definition set out at the beginning of the assessment program that has agreed with the lfb if however anyone feels that a risk has been wrongly assessed please let janice know
00:01:27 know now when you refer there or when the note refers there to the risk allocation uh did it mean the priority assigned to the fra item within mr stokes's action plan
00:01:38 action plan it did you did was your was the comment here an invitation to committee members to challenge whether that item should have been identified as a risk within the fra at all
00:01:49 all or to challenge the priority rating of the fra action having been identified by mr stokes um i believe it was an effort to identify any other areas um which may be causing delays in
00:02:02 um which may be causing delays in actions being completed so um i've been told that there were streamlining required and perhaps better definitions of of what action to be taken was necessary and i was trying to
00:02:14 taken was necessary and i was trying to identify if people felt that there was there were other issues that needed to be addressed it doesn't say that though does it it says if anyone feels that a risk has been wrongly assessed
00:02:25 wrongly assessed please let janice know what i'm what i'm seeking to establish from you if you can help me
00:02:29 help me is whether uh what that meant was that that a risk was identified in the fra and shouldn't have been or had been
00:02:40 and shouldn't have been or had been wrongly priority rated i presume the latter right why would anybody need to challenge a priority grade set out in the action plan by your fire risk assessor i'm not sure that anybody did it was
00:02:53 i'm not sure that anybody did it was just um
00:02:54 just um in the uh well i'm not aware that anybody did i i think i was just clarifying that if they had
00:03:02 they had i was trying to be clear that i could establish all of the potential issues that colleagues may have had in relation to the fras and that was something that may have been one of them i was just trying to
00:03:13 been one of them i was just trying to clarify
00:03:13 clarify what has prompted you to issue that invitation to your colleagues um i can only really refer back to what i said earlier that there had been indications that um that perhaps
00:03:27 that um that perhaps definitions or explanations of what was required
00:03:30 required weren't either adequate or um there there'd been sort of some grumblings about some some of the the fire risk assessment so i was trying to find
00:03:37 find find out the details right i mean whatever mr whatever qualifications mr stakes might or might not not have had none of your colleagues were adequately trained and qualified to be a fire risk
00:03:48 trained and qualified to be a fire risk assessor were they and exercise the same judgments about risk and level that mr stokes had exercised absolutely agree with you but i was just trying to tease out if there were still grumblings or people feeling that they had
00:03:59 feeling that they had issues yeah you see what it says is anyone feels that a risk has been wrongly assessed how would anyone in your team or anybody else's team within the tmo
00:04:08 the tmo have the knowledge expertise experience or training to know whether a risk had been wrongly assessed by your professional fire risk assessor i don't believe that they would but that doesn't mean that they didn't think that they had i was
00:04:19 they didn't think that they had i was trying to to clarify so that it could be investigated further i think you said that nobody in fact challenged the priority assigned by mr stokes either at that meeting or subsequently i i i'm aware of one instance where it was
00:04:32 i i'm aware of one instance where it was it was challenged subsequently yeah in relation to the adair fire yes but i'm not aware of any others you're not aware of any others right
00:04:47 now can we also continue with that note and look
00:04:50 and look at the bottom of page two and then to the top of page three fras is the title this actions are now to be progressed by property the
00:05:03 are now to be progressed by property the stats presented to the meeting show for each team the total number of actions allocated through the w-2 system since it was introduced on first of august and the numbers which have been fully completed partially completed
00:05:14 fully completed partially completed and those which that remain outstanding in order to provide each team with more comprehensive information on the status of their allocated actions janus agreed forward reports further she agreed that in advance of future
00:05:26 she agreed that in advance of future meetings she would provide each team with a current breakdown of all their actions to supplement the summary presented to this group the pre-w-2 backlog is approximately 1400
00:05:35 1400 and michael confirmed that he has raised orders with rd for the responsive repairs
00:05:39 repairs he will provide details to janice so that these actions can be recorded as partially complete with the aim for them all being fully completed by end of june in line with lfb deadline now did you
00:05:51 in line with lfb deadline now did you provide in in the event a breakdown of each team's actions to each team going forward i'm sure i would have done did you forward them reports yes and how did you provide them with
00:06:02 yes and how did you provide them with that information do you remember uh usually by email right did that breakdown include the color coding to indicate the priority rating of the outstanding actions accorded to them by mr stokes
00:06:15 accorded to them by mr stokes um i would i would believe so yes right do you know why that information well was that information also provided to those on the committee i can't recall is there any reason why
00:06:27 i can't recall is there any reason why it shouldn't have been none that i can think of now now we can see that the pre-w2 backlog was 1400 actions as of that date are you are you able to explain why so many outstanding actions had accrued
00:06:40 outstanding actions had accrued i'm not it's a lot isn't it it's a lot yeah
00:06:43 yeah now let's go to the uh ford in forward in the year to the next operational health and safety committee meeting 20th of june 2014 at tmo one double one triple zero nine
00:06:57 at tmo one double one triple zero nine seven eight four one triple zero nine seven eight four
00:07:04 we can see that you are present
00:07:08 yes and if we go to page two in the middle of the page under fra statistics we can see it says jw confirmed that there had been a lot of progress for the responsive
00:07:19 a lot of progress for the responsive repairs in relation to the fras that 121 jobs outstanding are on track to be completed by the end of june pm highlighted that there are 30 actions which are linked to a estate services training
00:07:30 training for example emergency lighting and smoke alarms which have been arranged pmsjw to clarify which of the actions could be defined as absolute requirements and which will best practice jw to clarify
00:07:41 clarify how many of the actions are reds brackets priorities brackets what information did you think mr madison was seeking um as i say here i was going to
00:07:53 um as i say here i was going to providing with the numbers of outstanding actions which had been classed as high priority read that's my understanding of what he was seeking it says that he asked you to clarify which of
00:08:04 that he asked you to clarify which of the actions could be defined as absolute requirements what was there to be clarified well there isn't it's just how many and which were were red and stay read
00:08:14 stay read but that was a matter of seeing the color and counting the numbers on your fingers why did he need your clarification of that um i'm thinking that perhaps i didn't copy it around to everybody in the group
00:08:25 copy it around to everybody in the group perhaps i sent the breakdown to the the teams and the head of so perhaps alex um and his equivalent heads of got the breakdown
00:08:37 equivalent heads of got the breakdown and peter just got the summary that's all i can suggest you see what he seems to be after at least according to this document is your
00:08:47 your clarification of which of the actions could be defined as absolute requirements and which were best practice what was he seeking what distinction was he seeking to draw there to the best of your understanding which required
00:08:59 of your understanding which required your clarification um i can't really speak for peter but that was my interpretation that what i would be giving him was a breakdown or the details of all of
00:09:10 was a breakdown or the details of all of the ones which had been originally identified as high priority because they remain high priority i'm i'm not going to tinker with priorities um and i would possibly have given him the original definition in that red was
00:09:21 the original definition in that red was statutory breach et cetera was he was the truth here that he was really get you getting you or seeking to get you to say that those mark read by carl stokes weren't really red or a sort of slightly lighter shade of
00:09:33 or a sort of slightly lighter shade of red i don't believe so in other words could be reprioritized as lower reds than some other reds um i don't believe so and i wouldn't have done that and
00:09:44 have done that and i was the one who was controlling the w-2 process so they wouldn't have been redesignated but why was why was there any clarification required which of course is an action point as we can see from this
00:09:55 an action point as we can see from this for you why not simply give him the action plan and say here you are peter that you can see the reds on this document that's probably what i did right um as i say he may not have been a recipient of that
00:10:06 recipient of that he may have only had the high level information and what he needs is a granular detail which i i was would have provided on request do you remember any discussion at this meeting
00:10:15 meeting about what it was that mr madison was really after no not really not more than i can have more than i've already added sorry
00:10:25 did you not at all form the impression that he was trying to trim down the red priority actions in order to get through the backlog more quickly no i didn't get that impression he was always anxious to
00:10:37 always anxious to to reduce the backlog and from what i could see he did try and get his teams to to give it priority he sometimes as we've discussed had issues about how things were defined or
00:10:48 issues about how things were defined or um how things were described or he and his view of streamlining as we said was was he wanted the assessor to tell him exactly what to do in every circumstance and i didn't think that was appropriate and and so we didn't always
00:11:01 appropriate and and so we didn't always agree but
00:11:02 agree but um no to be fair no i don't think that's well i can see that there might be disagreement on what as a matter of practicality needed to be done or could be done what i'm having difficulty with is how there could be any
00:11:14 there could be any uh disagreement about whether an item mark read by mr stokes was really read or not i i don't remember a disagreement i can't really add anything more to to what i've i've said i don't
00:11:25 what i've i've said i don't remember that being the case all right now let's move forward then eight months to february 2015. tmo double zero eight six nine four seven
00:11:35 seven nine please is the minute for the health and safety operational meeting 23rd of february 2015.
00:11:47 2015. and you are again recorded as present as is mr madison and if you go please to the bottom of page one we need to scroll down to that we can see another heading fra stats
00:11:59 we can see another heading fra stats do you see that there yes jw confirmed that there had been an improvement in the number of outstanding fras a b had a contractor who was undertaking the fras in each after a recent review lancaster west
00:12:11 after a recent review lancaster west had now become a priority and jw and siobhan rumble are in discussions about this and then it goes on to say pm suggested that it would be useful to have more information in relation to the
00:12:23 have more information in relation to the priority levels and nature of each outstanding fra pm and jw to discuss at a later stage and those words are in bold as you can see yes jw confirmed that the team are
00:12:34 see yes jw confirmed that the team are managing and prioritizing the fras and that there will always be some outstanding fras due to the nature of the assessments jw to split the outstanding fras into high medium and low categories with
00:12:45 high medium and low categories with targets
00:12:46 targets and you can see in the right hand column there the actions pm and jw to have the discussion that later at a later stage and jw to split the act the outstanding
00:12:58 and jw to split the act the outstanding fras
00:12:59 fras do you see that yes and the bold uh words
00:13:02 words and the action initials correspond don't they
00:13:06 they they do yeah yes now let's just look at those closely first of all taking the first one pm and jw to discuss at a later stage did you have a discussion
00:13:17 did you have a discussion with peter madison at a later stage i don't recall one i may have had but it doesn't
00:13:24 doesn't leave a lasting impression on me sorry no we you see we've seen no document of any such later discussion and had we had you would probably have seen it preparing to give evidence yes yes
00:13:34 yes yes so can we can we assume that either there was no such later discussion or if there was it wasn't recorded i think that's reasonable uh which was it of those two do you know i don't recollect a discussion so i'm
00:13:47 i don't recollect a discussion so i'm sorry i can't can't be definite um and then it goes to say
00:13:51 say jw to split as we can see did you do that
00:13:55 that did you split the outstandings into high medium and lay with targets i i believe so i um i know that peter particularly um kept on asking for more detail
00:14:06 um kept on asking for more detail at high level which was which was fine but actually i think the detail that he wanted was the level that his teams his team's head of alex and co already had um so i i think i'm
00:14:19 had um so i i think i'm came some way towards providing high-level information that he wanted um and then when barbara came she made a definitive position on on what we would we would look at every every two months but
00:14:30 look at every every two months but he could readily have access to i mean it would have taken five minutes for us to run a report and for me to identify the breakdown of his teams and the high medium and lower role could be filtered it was straightforward
00:14:44 could be filtered it was straightforward right can you just explain why it was necessary to have any discussion at a later stage or at all uh about the level and nature of each outstanding fra when all you had to do was put the
00:14:55 was put the significant findings and action plan from mr stokes into mr madison's hands i can't because like you say i i can't see a purpose for it but peter must have thought he had something
00:15:07 peter must have thought he had something he wanted to discuss see this is the second time we've seen this in eight months we saw the june minute and now we've got the february minute and on each occasion it looks like there's something that peter madison is wanting over and
00:15:18 that peter madison is wanting over and above you simply giving him the the action plan what was it
00:15:24 i i'm i have no recollection of of anything i know that he i mean i mean in some ways from my perspective it was good that he was focusing in on the fras and trying to identify how we could get
00:15:35 and trying to identify how we could get them completed and what if they're blockages identifying what they were but i can't remember anything specific um i would have always encouraged him to talk about them because it would mean that it was likely to translate into him putting
00:15:47 was likely to translate into him putting more pressure onto his staff so we would we would get more completed um so i wouldn't have discouraged meeting with him but i can't remember anything specific but same question again really in relation to the second
00:15:58 to the second uh to do to split the outstanding fras into high
00:16:02 into high medium and low categories with targets that had already been done for you by mr stokes so
00:16:06 stokes so why was that necessary um i can't really answer that and it already distributed on a regular basis to to alex and co who reported into peter han one to once with him so
00:16:18 han one to once with him so i don't know he must have felt it was necessary and it was something i could do pretty straightforwardly so i would have agreed to do it but um right i can't really add much to what's here really i mean one rational suggestion i have to put to
00:16:29 one rational suggestion i have to put to you is that mr madison wanted you to exercise your judgment
00:16:34 judgment in the light of what was practicable knowing what you knew about how the teams were managing fra items
00:16:42 items he wanted you to exercise your judgment to re-prioritize what mr stokes had already prioritized i i don't recall having that impression and i and i would never have done it and
00:16:54 and i and i would never have done it and i'm sure he would have known i would never have done it now mr madison's evidence about this was that he thought that this minute recorded
00:17:01 recorded him asking for the same information which he'd asked for back at the operational health and safety committee meeting on the 20th of june 2014 we'd seen earlier do you agree with that
00:17:12 you agree with that perhaps had you not provided information about priority levels and the nature of each outstanding to outstanding fra to peter madison before february 2015. yes i would i would have done but time
00:17:25 yes i would i would have done but time has moved on and and therefore so so would his outstanding list have changed so he's perhaps
00:17:30 perhaps asking for a refreshed version right but you can't help me explain why curing this in june or anytime between june and february june 14 and february
00:17:41 june and february june 14 and february 15 could not simply have been done by giving mr madison the significant action plan
00:17:47 plan and particularly the one from october 20th 2014. uh no i i i'm confident whatever he asked for i would have tried to provide um i can only assume that this is a refreshed or an updated version
00:17:59 refreshed or an updated version beyond that i'm sorry i can't comment really well let's look a little later into 2015 then tmo one triple zero nine four eight five please
00:18:10 now this is uh the minute of the meeting of the tmo health and safety committee
00:18:18 uh on the 16th of april 2015 and we can see that you are present you see that
00:18:25 see that yes at this stage i think it's right isn't it that the operations committee was still in existence
00:18:32 existence april 15 yes it was for another couple of months i believe right uh but this is the me this is the tmo health and safety committee properly so called
00:18:40 called uh if we go to page 2 please near the bottom of the page we can see that there is an item under paragraph 4.1 under the heading fire risk assessment fra update on outstanding actions 4.1 w2
00:18:54 fra update on outstanding actions 4.1 w2 a paper was circulated with the latest statistics on completed and outstanding fra actions for each team unfortunately there were still significant numbers of actions outstanding particularly for the contract management
00:19:05 particularly for the contract management and the response repairs rd janus advised that she had met with peter madison and also alex and in an effort to reduce the volume of actions highlighted by the assessor going forward we would be setting him up with remote
00:19:17 we would be setting him up with remote access to keystone this will enable him to check that items are on the asset registers and have been serviced within the required period obviously for equipment straight locations where our records cannot
00:19:28 locations where our records cannot confirm this to be the case an action will still be need to be raised janus is to report back on her imminent meeting with john tatum in respect of works progression by repairs direct
00:19:39 repairs direct action janus now the minutes refer to a meeting which had taken place between you
00:19:44 you alex bosman and peter madison to reduce the volume of actions so it seems from this
00:19:49 this do you remember what was discussed at that meeting um
00:19:53 um [Music]
00:19:57 i don't remember i don't remember specifically but i it leads on to the discussion about access remote access to keystone for for the assessor so
00:20:10 for for the assessor so i'm therefore assuming that it was partly about the volume of significant findings and actions that related to provision of evidence force for completed maintenance checks
00:20:21 completed maintenance checks apart from uh providing carl stokes with access
00:20:25 access to the keystone database do you know what other measures had been implemented in order to reduce the numbers of outstanding fra items i can't recall as i sit here now sorry
00:20:36 now sorry um because they were both involved then it would have been a wider ranging conversation presumably about um all of their actions and and whether there were um how they were doing how they were
00:20:48 um how they were doing how they were going to expedite them but i i can't remember the detail other than the keystone issue do you remember why mr stakes
00:20:53 mr stakes had not been provided with access to the keystone database before uh april 2016. no i mean the keystone date sorry the keystone database was um constantly
00:21:05 the keystone database was um constantly under development um and i think i think the initial records that went in and were comprehensive were i think possibly gas servicing so it was being developed and they were
00:21:14 they were adding um one particular contract at a time um so it's possible that if he had early access he still wouldn't have had
00:21:21 had any of the information um that he actually required by this time i think it had electrical installation checks and probably um maybe lightning protection i'm not too
00:21:32 maybe lightning protection i'm not too sure so there may have been things that he would have regularly be requesting that he could now remotely access but possibly it's they're possibly only been
00:21:40 been um comprehensively reviewed um recently i i don't know to be honest it depends when they all came on stream you know when i went when keystone did come on stream
00:21:52 come on stream um so keystone has had been around for i think kind of it was around once selves it's we've had it for a number of years
00:21:59 years but it's being developed and each specific
00:22:03 specific um contract is being added i think pretty much one at a time to make sure that
00:22:07 that all of the certificates have been audited and everything that's going in there
00:22:11 there meets the required standard um and so it's a fairly rigorous process but i think they were doing it one contract at a time
00:22:18 a time so what i'm saying is i i think that perhaps it took until this sort of time before the information store there was was the information that was being requested by the assessor uh i see uh you didn't provide
00:22:32 i see uh you didn't provide mr stakes with access to w-2 did you no i didn't i don't even know if we could have provided it remotely i don't think remote access was something that was um readily available it was just in terms of keystone
00:22:43 just in terms of keystone right did you inquire as to whether it was possible no but i'm pretty confident it wasn't but i didn't i don't remember specifically inquiring right
00:22:54 right was it not possible to provide mr stokes periodically at least with snapshots of or run-offs from the w-2 database of course did you do that um i possibly did
00:23:07 um i possibly did i don't i don't recall he he understood how the system worked i would have shown him the spreadsheets yes that was definitely possible pretty straightforwardly really but i i may have i think i probably did
00:23:19 but i i may have i think i probably did in relation to specific blocks where he was requesting progress update but i don't know that i ever gave him um a complete report of the whole other than contract management this
00:23:31 other than contract management this minute identifies responsive repairs or repairs direct there's a particular focus for outstanding actions and it looks as if you plan to meet john tatum regarding works progression by repairs direct did
00:23:43 works progression by repairs direct did that meeting take place do you remember um probably it did because i was meeting with john tatum was the response repost manager and and it was peop it was him and his predecessors and his successors that i was regularly
00:23:54 was regularly um meeting and cajoling and trying to get an understanding of why we weren't completing the responsive actions we were on then in time to the end of july 2015 uh
00:24:06 tmo10010039
00:24:10 and this is the minute of the health and safety committee meeting held on the 31st of july 2015. we can see that barbara matthews is present in the chair was that her first health and safety committee meeting
00:24:21 and safety committee meeting i believe it was yes you're identified as second
00:24:24 as second in attendance there if we go to page three please uh again section 4.1 fras w2 workflow there's a long text there
00:24:37 w2 workflow there's a long text there and you can see that there's discussion of the statistics and it says barbara highlighted the level of outstanding actions particularly for contract management and also the responsive repairs
00:24:48 also the responsive repairs you see that um now you had a you produced a statistics paper didn't you for that meeting yes uh and if we can look at that it's a tmo1 triple zero
00:24:59 tmo1 triple zero nine six six two
00:25:04 and we can see there that uh this is a an analysis of an overall breakdown of fra actions and the total and we could see that the fully completed 941 partially partially completed 95 and
00:25:17 partially partially completed 95 and outstanding 814 was it that figure that she suggested that barbara matthews suggested was too high
00:25:24 high i would say so yes yes why were there so many outstanding actions
00:25:30 i'm really struggling to give you answers to these questions because the because the actions fell outside of my control um
00:25:38 we asked questions we challenged we but i can't really give you a definitive um view from the teams who weren't who weren't completing the actions because no doubt there were lots of
00:25:49 because no doubt there were lots of things that i was not aware of um i i know as we've said that there were sometimes issues with contractors there were sometimes issues with the volumes of work but i can't really give you a meaningful
00:26:01 i can't really give you a meaningful answer because because i don't have it see we we've seen you historically expressing concern about the level of outstanding actions as early as if it was early 2012 we've seen the
00:26:13 if it was early 2012 we've seen the hodgson report draft and final july and september 2013. this is now
00:26:19 is now two years later why had you or your team not got on top of resolving the problems with outstanding fra actions
00:26:28 actions by this time but you appreciate that my role was to allocate and chase and escalate and and do everything i can and i was doing that but it clearly
00:26:40 and i was doing that but it clearly wasn't enough um so well what was the problem well that's what i'm saying to you as we sit here now the those teams i i don't i can't give you chapter and
00:26:53 i i don't i can't give you chapter and verse for why these things were not happening i can tell you what i was advised of and i have done um but i'm not in a position to give you
00:27:04 but i'm not in a position to give you all of the reasons why these are outstanding i'm just i'm sorry i'm just not no but you might be able to give me a reason for not taking a step back and asking yourself the question i've asked you which is given that matt hodgson had
00:27:17 which is given that matt hodgson had raised this problem in the summer of 2013
00:27:20 2013 how how could it come about that two years later such a significant proportion of fra actions remained outstanding did you ask yourself that question of course did you ask that question
00:27:32 course did you ask that question yes regularly whenever i was going to have conversations with alex bosman and john tatum and and all of those people repeatedly and ongoingly and when i was
00:27:43 repeatedly and ongoingly and when i was escalating it to anthony and then at this stage barbara sasha in the ops group
00:27:48 group all of those people you can see from all of the minutes that they were being raised repeatedly and statistics were being circulated repeatedly now looking at the breakdown if we go to
00:28:01 now looking at the breakdown if we go to page
00:28:02 page two we've got some data there we can see that uh
00:28:11 382 of the outstanding actions had been assigned to a r contract management do you see that yes yes why were so many actions outstanding for that team
00:28:29 yes they hadn't been completed because we hadn't got their whatever it was that was covered which was often maintenance certification hadn't been provided and i can't close them down until i've i've had sight of those things
00:28:40 things it'll be in a whole range of of of matters
00:28:44 matters but unless i've got evidence that they're completed i can't close it down no clearly uh but my my question is really a slightly more profound one which was
00:28:51 which was well what was the problem particularly with contract management that meant that so many
00:28:56 so many uh items 382 in all at that time were outstanding
00:29:04 they did get a substantial volume of actions
00:29:08 actions um partly because the fire um information and could couldn't be accessed remotely in keystone because that would so that would have prevented
00:29:19 would have prevented a volume um
00:29:22 and sorry as we sit here now i i don't know that i can give you what you need from me i can't give you an undertaking of why that is the case
00:29:31 the case um but all of the contract management issues sat in one place so there was clearly problems with getting either getting a certification or or
00:29:42 either getting a certification or or just providing it to me and some of those will have been complicated things that maybe needed procurement so some of them will have been challenging in terms of time to complete but i
00:29:55 time to complete but i i'm sorry with the same answer
00:30:00 be given by you in relation to the figure for responsive repairs as we see at the bottom of that page 297 yes okay let's um go
00:30:12 to page three please [Applause] uh of the minute uh back to the minute
00:30:23 uh of the minute uh back to the minute it's tmo10010039
00:30:31 and we can see their paragraph 4.1 which i picked out to you before six lines up from the bottom of that section the minutes record as follows barbara advised do you see yes yes
00:30:43 barbara advised do you see yes yes barbara advised that more information on the outstanding fra actions needs to be provided to the committee
00:30:49 committee although the total provided an indication they do not provide the full picture
00:30:53 picture janus was requested to investigate providing a more meaningful breakdown of outstanding actions so that the committee are better able to see the detail and what work program will be required to clear them now
00:31:06 to clear them now that's and that gave rise to an action item on the right hand side in that column j ray to provide a more comprehensive breakdown of outstanding free actions for next meeting you see
00:31:17 free actions for next meeting you see that yes what information did barbara matthews
00:31:20 matthews consider so far as you remember was missing
00:31:23 missing so that the full picture wasn't clear to her
00:31:27 her um sorry without looking at the associated stats for that um well we could have i'm happy to put it back up again i mean it may be that i hadn't included
00:31:38 i mean it may be that i hadn't included the high medium low i'm not really sure um right i think you say that and indeed it is true that you didn't it was that what the best of your recollection was that
00:31:50 the best of your recollection was that what she was after what i recall is um i believe that we then started to add the priorities and possibly not at that
00:31:59 that stage perhaps later we then started to have an age profile within the priorities so you could see how many of the high the right standing were aged uh three to four months and so on so it became
00:32:12 on so it became um there was sort of we it it developed sorry it developed as people were more specific about what they wanted to see and how they wanted it
00:32:22 it to to be provided and that enabled barbara to see very clearly we still knew that we had 300
00:32:30 300 plus still outstanding in terms of alex's team however it meant that that 300 could be divided um you could see very clearly what was very historic and what was what had
00:32:41 very historic and what was what had recently been right so you're identifying i think two further kinds of data is this right first of all the risk level high medium low yes and secondly what you call an age an aged profile so
00:32:54 what you call an age an aged profile so naught to three months three to six months six months to twelve months all that
00:32:57 that all that kind of yes i see can i just ask you i mean clearly that information had not been collated and presented to the tma health and safety uh committee before this time why did it take the arrival of barbara
00:33:09 why did it take the arrival of barbara matthews to identify that omission in the data
00:33:15 um i'm not really sure that anyone had asked for it before and the teams who were responsible for the actions were getting their specific data
00:33:24 data on a very regular basis so um yeah i mean i mean she had clearly seen something you hadn't is that fair yeah that's fair she's the executive director that's her her role right and can you account
00:33:36 her her role right and can you account for why she had seen it but you haven't uh no i can't um now on the same day you attended at 2 p.m you attended an operational health and
00:33:47 you attended an operational health and safety committee meeting also with barbara matthews and peter madison and that we find at tmo12009039
00:33:59 madison and that we find at tmo12009039 let's just look at the first page of that
00:34:02 there it is and we can see who is there and if we gave please in the document to page four
00:34:08 page four item 3.2 halfway down you can see that the minutes record as follows rd have reviewed all the fras and health and safety actions currently waiting for rd to program that
00:34:19 currently waiting for rd to program that work and will then raise the orders for the blocks bm asks to see the key things and the timing for it pm asks for a breakdown by a priority and age to make it clear where the risks are there needs to be an ongoing breakdown
00:34:30 there needs to be an ongoing breakdown of the list pm suggested a meeting to discuss interface between rd and abs team cm to organize meeting with pm ab chris davis and jw now uh working on his way through the
00:34:41 now uh working on his way through the forest of
00:34:42 forest of initials uh it's fair to say isn't it that this was a yet further request by miss matthews and mr madison certainly for more ongoing detailed information about outstanding fra actions
00:34:54 outstanding fra actions yes yes did you take any action as a response to that in response to that request yeah i believe so what did you do well i presume you're going to take me to the next set of minutes and we'll
00:35:05 to the next set of minutes and we'll know about it but um i believe that i would have um endeavoured to to meet their requirements um right and again was there any
00:35:17 um right and again was there any question posed of you about why these matters were still being uh examined if that's the right word in july 2015 when matt hodgson had picked these issues up two years before
00:35:28 these issues up two years before is that not something raised with you um i don't recall it being raised with me right
00:35:32 right and now if we go to the next meeting this is the 29th september 2015 tmo100-44175 i'll show you page one
00:35:46 by now i think the operations uh health and safety committee had fallen away and everything was being dealt with by the um corporate health and safety committee wasn't it yes yes
00:35:57 wasn't it yes yes you can see the date at the top you could see who was present you included as well as barbara matthews and peter madison
00:36:02 madison if we go to page 2 please bottom of page 2
00:36:05 2 we'll see paragraph 3.1 there it is there have been an additional 200 completed action since july added that the age profile needs to be monitored carefully going forward
00:36:16 monitored carefully going forward was it was it your responsibility to monitor those actions
00:36:22 um it was my responsibility to have oversight of the foa process but in terms of monitoring compliance then i that wasn't my
00:36:33 compliance then i that wasn't my exclusive responsibility it was the health and safety committee and
00:36:38 and um and that included me obviously and the executive director with health and safety responsibility right you see where he's where pm adds the the age
00:36:48 age profile needs to be monitored carefully going forward it looks as if there's a on the face of it an implicit criticism uh that the age profile had not been monitored as carefully as it should have been is that was that
00:37:00 as it should have been is that was that the case
00:37:02 the case no i don't think it was the case well i mean
00:37:05 mean what then what did mr madison mean when he says that the age profile needs to be monitored carefully going forward well exactly what it says that we should continue monitoring it going forward i mean we've been providing significant
00:37:18 i mean we've been providing significant amounts of information to each of the teams
00:37:20 teams with all of the status of all of their actions on a regular basis so the information was readily available and they just were requesting that i prefer
00:37:30 prefer provided more in my summary my high level summary to the health and safety committee
00:37:34 committee and i've taken that on board um i i think that is all he means it's just so did you as a result of this request from mr madison change your approach so as to provide an
00:37:45 change your approach so as to provide an aged and
00:37:47 aged and aged outstandings i believe so i see um let's then just turn the page please to the top of page three paragraph 3.2 it says a b had been going through the
00:37:58 it says a b had been going through the list of actions and allocating them to the appropriate contractor pm confirmed that the data will be cleansed in a meeting tomorrow just pausing there what was that about what was cleansing the data about
00:38:09 what was cleansing the data about i have no idea no um pm also met with jw to discuss streamlining the process uh what did that mean streamlining the process
00:38:18 process um i think it just refers back to what we've mentioned before about where possible um peter wanting carl to say this is what
00:38:31 peter wanting carl to say this is what you need to do rather than give a range of options um that's my recommendation
00:38:42 i see do you remember the content of the actual discussion about and about what it was that mr madison was proposing no sorry
00:38:51 his evidence was that he felt that the wording of the fras needed to be more precise and specific so that you could actually action them and turn them instantly into a form of words for a works order
00:39:02 words for a works order rather than sending a team out to investigate particularly if it's not in their area of expertise that's the flavor of what heath understood and that's day one two three at page 46 line 18 and following
00:39:13 at page 46 line 18 and following but did you is that does that give the flavor of what you understood him to mean
00:39:18 mean yes i mean he wanted it to be as unambiguous as possible which is entirely desirable um but he did want to be very quickly able to convert the required action
00:39:29 the required action into an instruction for for a contractor that isn't always going to work completely um but where it was possible then we would endeavor to try and do it now so you told us earlier it was your evidence i think yesterday as well as
00:39:40 evidence i think yesterday as well as this morning that as far as you were concerned it was for the tmo to decide what to do but for the effort but the fire risk assessor to decide what the where the defects were the
00:39:51 what the where the defects were the emissions were in compliance that's right and my point is
00:39:56 is that in circumstances where there is only one option and a carl is can only provide one option then it's legitimate for him to provide it in a form of words that if it's acceptable to him
00:40:07 that if it's acceptable to him could then be lifted and put into a works order yes was it your view at the time that mr madison hadn't really understood the role of the fire risk assessor and was asking him to do something that that he wasn't really either qualified
00:40:18 that he wasn't really either qualified to do or had time and time and uh space to do i think he was just looking he saw a problem and he was looking at possible ways of moving it forward i understand that but i understand that
00:40:29 understand that but i understand that entirely
00:40:31 entirely but but was it your understanding that mr madison hadn't really understood the limits of what a fire risk assessor can do
00:40:39 can do and was perhaps putting or seeking to put more onto mr stakes's shoulders than was practicable i don't know if i agree with that i i think just to go back to what i said
00:40:50 think just to go back to what i said before i think he was looking at ways of resolving problems i think if providing we pushed back and said that's not legitimate or that's our role then i think he largely accepted that let's look at tm mode one double zero
00:41:01 let's look at tm mode one double zero one double zero six six
00:41:12 [Applause]
00:41:15 this is the health and safety committee meeting
00:41:22 document looks like the figures which were prepared for that meeting if you look at page one and you could see the overall breakdown of fra actions and the total outstanding
00:41:35 of fra actions and the total outstanding 812. and if we go to page three to start with
00:41:39 with we can see that
00:41:42 this is the breakdown of neighborhood management actions fra actions do you see that
00:41:47 see that yes and then if you go to page four you can see that those statistics are then broken down further into categories total number outstanding
00:41:58 into categories total number outstanding outstand and then you've got outstanding since 2013 2014 2015 across the page yes yes
00:42:07 and this one also produced in november 2015
00:42:12 2015 uh in the same format we don't need to go to it but the reference is
00:42:18 tmo10011191 pages four and five what was it that caused you to alter the format to this more detailed breakdown i was following up on what had been requested of me at the previous meeting
00:42:30 requested of me at the previous meeting but also i discovered that um there was a possibility of extracting the statistics from the w-2 system that i had previously been unaware of the detail of and that's where this was lifted from i
00:42:43 and that's where this was lifted from i see but this was in response i think was it to pick mr madison's long-standing requests for more detail yes yes and also in part your own discovery of the functionality of the w-2 system yes
00:42:54 w-2 system yes yes i see then if we go into 2016 tmo double one double zero one one nine one
00:43:01 one zero tmo one double zero one one nine one zero
00:43:06 one zero health and safety committee meeting minutes ninth of january 2016. yeah this is an fra summaries report for that meeting and if you scroll through to page four just looking
00:43:18 scroll through to page four just looking at it let's scroll through the pages that's page one that's page two age profile of outstanding actions now we can see the age profile page three uh is a
00:43:29 page three uh is a health and safety inspections and our a team summary and then page four progress with completing actions it's rather less detailed isn't it than the detailed reports that you'd produced for
00:43:40 detailed reports that you'd produced for the september and november tmo health and safety committee meetings and i say that because it's gotten a color coded breakdown as we've seen in september and november 2015. okay but
00:43:51 in september and november 2015. okay but this these are health and safety inspection actions not fire risk assessment actions and they wouldn't be categorized in the same way these these are and the health and safety and property risk assessments are what my colleague
00:44:03 risk assessments are what my colleague adrian
00:44:03 adrian does and when he's out on site and these actions
00:44:06 actions relate to his findings so that they wouldn't be categorized high medium low in the way that the fire risk assessment the
00:44:12 the further up um in the document that that is fire risk assessment yes we've actually merged the information was put together in the one appendix oh let's just be a bit more a bit more uh a bit more constructive
00:44:26 a bit more uh a bit more constructive about this so pages one and two relate to fire team fighting fire risk assessments don't they yeah i believe so well look at what's going on risk team summary yes and then you've got the groups again and then you've got fully completed
00:44:38 then you've got fully completed outstanding partially completed yes uh and you've got the still some big numbers haven't you uh for um uh outstandings relatively for uh contract management
00:44:51 relatively for uh contract management and responsive repairs yes yes and then page two progress with completing action same again but this time you do have an age profile but you've got no risk you've got no color coded risk there
00:45:02 color coded risk there no why did that disappear um could you sorry could you scroll down to the next page yes of course page three okay um
00:45:13 of course page three okay um i can only
00:45:16 i prepared this it was actually it actually took longer than you would think
00:45:21 think and i think i may just have run out of time in order to to split it between the difference so i think it was just just um time unfortunately i see okay now then
00:45:31 now then if we uh go uh to the minutes of this meeting that's at tmo
00:45:39 tmo double zero eight four zero five zero zero
00:45:44 that's the meeting which th presented
00:45:52 first of all first page you can see the date 19th of january 2016. yes uh you were there and then if we go to page
00:46:00 to page 4 near the top of the page we can see again
00:46:03 again that peter madison
00:46:10 paragraph 3.2 peter madison says pm asked for a copy of the detail behind this report pm noted that the system should be more robust to ensure actions are escalated
00:46:21 robust to ensure actions are escalated if they are out of time or allocated to staff
00:46:23 staff who are no longer with the organization gw advised the process will be reviewed to avoid outstanding historic actions uh what what further detail was mr madison after now
00:46:36 further detail was mr madison after now i don't actually know because we're providing
00:46:40 providing lots of detail to all of the teams with direct responsibility for the actions we're providing that regularly they can see very clearly the risk profile
00:46:49 profile and the age profile um and this is just additional an additional tier to to let the subcommittee have the committee have scrutiny at their level um and
00:47:01 have scrutiny at their level um and all of the teams sit under people who are at this committee and they have all of the details so i'm actually not sure and it got to the stage where i was spending quite a lot of time producing
00:47:12 spending quite a lot of time producing the report and there i think there was a limit to what i could reasonably you know put into it but but was he asking that the data that you had included
00:47:21 included in your september and november reports which we saw with the color coding be reinstated for example is that what he was after it doesn't say that here so that's why i'm asking you
00:47:33 i'm asking you i i would think that if he was that i would have made sure that that was minuted so that i was absolutely clear
00:47:40 clear so the problem with this data even at this stage is that you can't see which actions are post-date in other words which which have gone past their due date
00:47:49 due date nor can you see what level of risk priority they have i mean why is that critical data missing particularly given that it had been requested for
00:48:01 been requested for months now by mr madison
00:48:05 i can only reiter what i'm telling you is that i was constantly sending out tracker information to all of the teams
00:48:13 teams so all of the heads of who were in a position to action the the actions had all of that on a regular basis could run their own had access to w-2 yes but sorry i'm going to interrupt you that
00:48:24 sorry i'm going to interrupt you that may be downstream but this is upstream this is up to top or
00:48:29 or nearly top management within the health and safety sphere within the tmo why not give them a single set of data which tells you how many of the f what fras were
00:48:40 how many of the f what fras were outstanding within each contract group how long each one had been outstanding for whether it was past due and what its level of risk was so that someone like barbara matthews or peter madison could actually get a grip on this
00:48:50 on this at a glance um
00:48:54 i can't give you an explanation other than time
00:48:58 than time that actually it took longer than you think it did to produce it so i produced what i could and the level of detail here i appreciate isn't as comprehensive as
00:49:07 as as it should have been or could have been but it still gives a very a fairly accurate flavor of what's outstanding and the age profile of what's outstanding and yes there could have been more
00:49:17 been more but i still think there's quite a lot of information here on which to make um a judgment did you go to peter madison or barbara matthews and say look in order for me to produce this data in a form which is
00:49:29 a form which is really readily digestible by you so that you can take executive decisions on it i need more help i need an extra pair of hands it's going to take me all day twice a week to do this i haven't got time did
00:49:41 week to do this i haven't got time did you ever
00:49:41 you ever have a conversation with either of them along those lines i didn't have that conversation with peter madison i may well have had that conversation with barbara um but barbara also
00:49:53 um but barbara also was fairly exacting about what she she wanted so i think i probably tweaked this again subsequently in order to get what she wanted at that level at that meeting was it the
00:50:06 at that level at that meeting was it the position
00:50:06 position and forgive this question that you needed help but didn't realize it or was it that you realized you needed help but
00:50:14 help but for whatever reason just didn't ask for it
00:50:22 i could have always used more resource it was pretty obvious that i could have always used more resource but that wasn't going to be made available that that wasn't available so i had to work within the constraints
00:50:33 so i had to work within the constraints of what i had and and i re-prioritized and always tried to make sure that i identified the highest priority things and it may be that when it came to producing this
00:50:45 be that when it came to producing this report
00:50:45 report something else on that day was of significant importance and therefore i didn't have the time to provide that level of detail but i can't tell you because i wouldn't have kept that
00:50:56 because i wouldn't have kept that detailed record you see you say in the last answer that more resource wasn't going to be made available it wasn't available how did you know that
00:51:08 did you know that i just know that i i just know that you didn't ask you wouldn't know would you yeah well i would have i would have asked anthony and in those days and it just it just wasn't available
00:51:21 did he ever say to you or barbara matthews ever say to you you can't have any more help tough luck you'll just have to manage as best you can but by the way we need all this granular data no they wouldn't have said that um
00:51:34 no they wouldn't have said that um can i then ask you to look please at page
00:51:39 page uh yes i'm sorry we're still on this note
00:51:42 note 3.2 um he
00:51:46 3.2 um he he notes there or says there uh that that there are um actions being allocated to staff who are no longer within the organization what what were actions being allocated
00:51:58 what what were actions being allocated to staff who who were no longer with the tmo
00:52:00 tmo no they weren't but when people left the organization and i went to the respective team and said this person has left he has a w-2 inbox with actions who do i reallocate them to that didn't
00:52:14 who do i reallocate them to that didn't always
00:52:14 always get a straight answer immediately right why was that i i is it because there was no one um perhaps there might have been um an interim then they knew that person
00:52:25 um an interim then they knew that person was there for a short term um or i can't really i just know that there was sometimes a delay which meant that they were sat in a box
00:52:33 a box so i was lobbying to get an answer and so i was well aware of that being a problem
00:52:38 problem um occasionally not not often but actually particularly in relation to responsive repairs where we seem to turn over stuff and it says uh here that uh peter madison uh asked that the system
00:52:49 peter madison uh asked that the system should be more robust to ensure actions are escalated if they're out of time were actions not being escalated even though they were out of time they were escalated to the heads of
00:53:00 they were escalated to the heads of um to alex who was heads of of contract management they were escalated to the head of repairs there were regular meetings with all of those people um i would go and speak to those people i would
00:53:11 those people i would physically sometimes take them a copy of their tracker and highlight the things which were out of time so yes they were being escalated they were but you see the impression given by this is that uh the system needed to be robust to
00:53:22 uh the system needed to be robust to ensure actions are escalated if they're out of time which rather suggests that they weren't being it does suggest that yes is that the case no it isn't the case and to be honest peter wasn't really
00:53:33 and to be honest peter wasn't really involved in the detail in the day-to-day detail of it so he wouldn't necessarily have known what we had in place to escalate issues what was your view of mr madison's suggestion that the system needed to be more robust my view was that the system
00:53:47 more robust my view was that the system was reasonably robust where it broke down was actually translating the actions into completed bits of work and and that sat with the respective operations teams
00:53:58 sat with the respective operations teams why didn't you tell peter madison that and have it recorded in a minute i probably did tell him that but it's not recorded all right now then in 2016 april 2016 now
00:54:09 now further meeting of the health and safety committee tmo10013060
00:54:16 this is the meeting of the 12th of april 2016. page one there you are in attendance as well as barbara matthews and peter madison uh if we go to page three
00:54:27 we go to page three item four one near the middle of the page
00:54:31 page um it says jw welcome a significant or the significant drop in the number of outstanding actions for both fras and h actions bm acknowledged the progress
00:54:42 actions bm acknowledged the progress made and advised that the chief executive remained anxious that all actions older than six months should be completed as a matter of urgency a boss i think alex bosman added that his team currently has a further 50 plus actions
00:54:54 currently has a further 50 plus actions which have been confirmed as complete and will be fully completed on w-2 asap um now let's look at the statistics which we understand you produced for
00:55:05 which we understand you produced for this meeting at tmo10012642
00:55:14 now the meeting date is the 12th of april 2016. the document that i'm showing you now on the screen uh is dated the 6th of april 2016 10
00:55:25 uh is dated the 6th of april 2016 10 days beforehand according to its file names we've been able to identify it and there's an email of the 8th of april which attaches this document
00:55:35 document i went we don't need to go to it it's tmo one double zero one two six six one uh that is the basis on which i'm putting to you that this document was what was presented to the 12th of april meeting
00:55:45 meeting it's quite i tried to get the papers out in advance so people had the chance to scrutinize so it's quite likely to be the case
00:55:51 the case very good now on that basis let me let's look at this document you can see uh that in the outstanding column on
00:55:59 column on page one there is a total of 243 outstanding fra actions yes yes and if we examine the previous breakdown produced uh by you which was the 18th of january
00:56:10 uh by you which was the 18th of january 2016 so four months before uh let's have that at the same time tm010011910 tm01 tmo10011910
00:56:26 tm01 tmo10011910 we can see that there were 296 actions outstanding okay so uh we we could we look at the figure for january 296 in the second column
00:56:37 for january 296 in the second column there
00:56:38 there and we look at the figure in the second column 243. just looking at the figure for outstanding actions it's only reduced by 53 actions since the previous meeting
00:56:49 53 actions since the previous meeting why was this considered to be a significant drop um but we've added 300 more actions haven't we in the in the meantime
00:57:00 we um the total actions allocated originally were 2206 and now they're 2515 if i'm reading that correctly yeah yes so we so we have added
00:57:12 so we so we have added significantly more and the fully completed total reflects that doesn't it from 1794 to 2132.
00:57:21 2132. so i think overall there was a significant movement in the right direction
00:57:25 direction well i can see that it's probably not negligible but but maybe we're quibbling about the word significantly but mathematically it's correct isn't it that the number of outstandings went down from 296 to 243
00:57:36 down from 296 to 243 so by 53 yes yes and although one has to allow for the increase in outstanding in in uh new new allocated actions you you're unable to tell me how many of those
00:57:47 unable to tell me how many of those were or weren't outstand where i went past due by that date i'm sorry no no september 2016 is where we next go
00:57:59 tm00840753 health and safety committee 13th september 2016. page one you're there barbara mathews is there
00:58:15 yes yes yes now we see that now page two please paragraph 4.1
00:58:26 uh under fra actions bm that's barbara matthews
00:58:29 matthews raised concern that there was still a volume of actions outstanding we haven't got there yet no we haven't i'm sorry page 2 4.1 bm raised concerned that there was
00:58:40 4.1 bm raised concerned that there was still a volume of actions outstanding and reiterated the need for these to be given priority and completed asap you see that yes uh
00:58:51 yes uh can you wait can you explain why there was still
00:58:55 was still an ongoing issue with fra actions still not being given priority and being completed as soon as possible this is now september 2016. nope some of them some of them will be
00:59:07 nope some of them some of them will be complex um but i don't have the detail and i can't give you an explanation i it really would be for the contract management team and the repairs team to provide the detail and i i don't have that i'm afraid i
00:59:20 and i i don't have that i'm afraid i mean clearly you were at the meeting your boss says she's concerned about the volume of actions what
00:59:30 did you explain to her that either her concern was misplaced or that so far it was as it was justified
00:59:38 justified you were sorting out the problem
00:59:42 barbara was very clear on the process she knew where the action sat and she knew who was responsible for completing them so it was a forum where quite a lot of those people were represented were present or represented and it's her
00:59:54 present or represented and it's her opportunity to to make her position clear that people needed to give them the priority that they were due everybody with actions under the fra needed to treat them with priority she
01:00:06 needed to treat them with priority she wasn't directing that solely at me the word outstanding there do you remember that she was concerned that there was still a volume of actions which were outstanding whenever the due date was
01:00:18 outstanding whenever the due date was or or past due did outstanding mean past due
01:00:23 due in that context there i believe it meant actions in need of being completed because that was always my perspective i i wouldn't have we had the age profile so we can see
01:00:36 we had the age profile so we can see what age
01:00:37 what age those are that are still outstanding have
01:00:41 have but in my view outstanding means things have been identified and need to be completed but have yet not been completed um with respect i wonder if that's really a right way of understanding it
01:00:52 understanding it you see she she says according to this note at any rate that she's concerned that there's still a volume of actions outstanding and reiterated the need for these to be given priority and completed asap she's clearly
01:01:04 and completed asap she's clearly directing herself to the actions which aren't simply outstanding but which have remained outstanding past their due date otherwise everything would be a priority wouldn't it
01:01:15 wouldn't it they are of higher priority yes but but she she wants them all completed we both do
01:01:19 do but but what's the these then these what the need for these to be given priority what did you understand she wanted to be given priority the fire risk assessment actions
01:01:30 risk assessment actions all of them yes how could all of the virus contestant actions be given priority
01:01:36 priority well the teams who have acquired these actions have have other responsibilities as well i think she's trying to say can you treat this as one of your main priorities
01:01:48 priorities in your overall scheme of what you're what you're doing well in priority to what
01:01:52 what well the the other activities that they're responsible for progressing you've got contract management team who manage to monitor contractors and let contracts and and do all the range of things that they do
01:02:03 all the range of things that they do in addition unless i've sorry if i've got the wrong under the stick well i'm just wondering because um if you look at that first line with the reference there being still a volume of actions outstanding yes um
01:02:17 you always as you've explained to us there were always going to be some um requirements outstanding because new requirements were coming up all the time so the the natural emphasis of that
01:02:30 time so the the natural emphasis of that is things that have been outstanding for a long time isn't it i overdue um well perhaps otherwise it's just a statement of the obvious
01:02:41 it's just a statement of the obvious yeah but sometimes that's necessary i mean well because we'd struggled with this i think she was taking every opportunity to um to to get people to give it the priority that it required i mean you may
01:02:52 priority that it required i mean you may be right and i may be wrong but i can only
01:02:54 only tell you that my well you were there and i wasn't
01:02:58 i wasn't i wish i could remember i'm just reading this as well as it hits me off the page but if you think if you can remember a different tenant at the meeting then obviously tennis i i think because because we had
01:03:09 i i think because because we had struggled with these for so long i don't think she was she was going to be seen to take a position where it's okay you don't have to worry about these so much you need to cons i think she she
01:03:20 so much you need to cons i think she she wanted the message to be consistent and she didn't want to give anyone an opportunity to go well you didn't tell us to concentrate on that so right um but but hopefully she can advise you herself well we possibly
01:03:33 advise you herself well we possibly as as the chairman has said you were there and there are two possibilities aren't there either she's expressing concern about the sheer number of actions whether in an fra from yesterday or an
01:03:45 whether in an fra from yesterday or an fra from six months ago because of the size of the estate and the state of the buildings that's one possibility uh which we mean all of them the other possibility is that she's concerned
01:03:56 possibility is that she's concerned that there is a volume of actions outstanding meaning past due which needed priority which of those two alternatives did you understand her to be expressing
01:04:07 did you understand her to be expressing concern about
01:04:10 i believe that she was talking about fire risk assessment actions per se that they had to be given priority
01:04:18 priority clearly ones which are older will need to be done as a you know as the utmost priority but they all need to and ongoing they all need to have priority in the
01:04:30 priority in the job role that you do you must um you you must treat this with utmost priority
01:04:38 priority now she gives us a bit of assistance on this in her first statement okay uh tmo10049987
01:04:54 first statement okay uh tmo10049987 if that's the first page of her first statement to the inquiry and at page seven of that statement paragraph 35 she says this
01:05:08 she says this page 7 paragraph 35
01:05:12 thank you yes he says this if there were outstanding actions arising from the fra program
01:05:17 program i would emphasize the importance of clearing out outstanding actions as a matter of urgency at health and safety meetings by way of example
01:05:25 example in a health and safety committee meeting on 19th january 2017 i requested that each team with outstanding actions prepare a written report for the next meeting setting up the detail of each action and x and an explanation of what steps had
01:05:37 x and an explanation of what steps had been taken to progress these and when each would be fully completed i recall that this led to a mass clearing of actions i should say that while these were not actions that fell on my department but in my role as chair of the committee i
01:05:49 in my role as chair of the committee i was anxious to do what i could to get the number down now she refers there to emphasizing the importance of completing outstanding actions generally and specifically to requesting written reports other than those
01:06:01 reports other than those two examples do you know what else if anything miss matthews actually did or any other senior tma manager to help complete fra actions
01:06:12 um i think i think when we discussed this earlier i'm aware that she would have
01:06:15 have had dialogue with sasha jevins and also peter madison alex bosman graham webb all of the people who whose teams were responsible for progressing
01:06:27 teams were responsible for progressing actions i know that she was proactive about about her health and safety responsibilities um she also had a uh arena in relation to repairs direct so she had quite a lot of dialogue with with graham
01:06:39 quite a lot of dialogue with with graham and i know this is something that she would have discussed with him um so she had all of that going on i'm sure she would have engaged her exact team colleagues quite um vigorously about it as well yes
01:06:52 quite um vigorously about it as well yes now let's look at the 19th of january 2017 meeting the minutes of that meeting are a tmo100
01:07:05 this is the meeting she's referring to by way of her exemplar and if you go to page one you can see that she was there you were there mr madison was there if we go to page two paragraph 4.1
01:07:19 she says under the heading fra actions bm raised concern
01:07:26 that there are a large number of actions outstanding that are over 12 months at the next meeting each of the teams with outstanding actions will need to explain their action plan to clear these down
01:07:36 down and certainly at this meeting she's identifying the large number of actions outstanding that are over 12 months not outstanding as of yesterday because we had an fra yesterday
01:07:48 that that was i suggest to you the nature of her concern wasn't it i think i think it was one of the nature of her concern i think
01:07:59 one of the nature of her concern i think she was concerned to to get everyone to take this responsibilities seriously and to progress
01:08:05 progress um whatever action they needed to take um
01:08:08 um clearly anything over 12 months was going to be in the spotlight and and should be done as a matter of utmost priority and that's what she's trying to achieve but i don't think it was confined to that but that's the burden of it though isn't
01:08:20 but that's the burden of it though isn't it that's the thrust of it that she's concerned here that there are lots of actions
01:08:24 actions which are well past due not that there are lots of actions well it's not i i think we could debate this i i
01:08:33 this i i i i can only go on the note and i yeah i know and
01:08:36 know and what i would say is is often the detail of the meeting isn't all covered in the notes so sometimes i think perhaps my my recollection if not from this
01:08:48 my my recollection if not from this meeting
01:08:49 meeting from my endless discussions with barbara about
01:08:53 about fire risk assessments rro all of those is she felt very strongly that the organization needed to do whatever it could to take all of their responsibility serious and that meant completing actions
01:09:04 and that meant completing actions allocated to them in in the right time frame so yes this is what it says here i i agree with you but um i think it is wider than that was your understanding that only the
01:09:15 was your understanding that only the teams with actions outstanding over 12 months
01:09:18 months were required to provide an explanation or were all teams with any outstanding actions of any vintage to provide their action plan um it was my understanding that all teams should come along armed
01:09:29 that all teams should come along armed with if not in writing they should have um at least a verbal update on why they had actions outstanding see that wasn't the reason i'm asking you this is that wasn't mr madison's understanding
01:09:40 understanding his understanding day one two three page 98 line 17 was that he thought that only teams with actions older than 12 months needed to provide a report but that doesn't sound
01:09:51 provide a report but that doesn't sound as if that was what your understanding was
01:09:54 was it wasn't my understanding right uh mr chairman is that a convenient moment we're
01:09:58 we're we're we're still mid stream with this but um
01:10:01 but um we're making decisions it's probably as good a time as any isn't it yes we'll have a the afternoon break now then uh miss ray we'll assume at half past three please and again don't talk to anyone about your
01:10:12 again don't talk to anyone about your evidence while you're at the room
01:10:22 all right have our three then please
01:26:54 yes would you answer is ready to come back in please
01:27:07 all right yes ready to keep going yes well done
01:27:10 well done thank you yes mr miller yes uh mr chairman thank you um can i ask you next please to look at
01:27:19 tm010016217
01:27:23 [Applause]
01:27:29 now this is a document entitled fra's current progress with completion of actions paper four 10th of march 2017 you see that 10th of march 2017. can you
01:27:41 you see that 10th of march 2017. can you confirm that those are the statistics that you prepared for and presented to the tmo health and safety committee meeting on the 16th of march yes they would have been yes now if we go to page three of that document you'll
01:27:52 go to page three of that document you'll see that there's a section breakdown of actions
01:27:55 actions remaining incomplete after 12 plus months were those written were those the written explanations provided to barbara matthews that she had asked for yes i believe so i think some people did provide a verbal update
01:28:07 provide a verbal update uh instead of providing something in writing right and you you you can see that there are only two entries here yes yeah why is that that was all i received
01:28:18 received right i see was was there any discussion at the meeting about whether those were considered a sufficient explanation by members of the committee or by barbara matthews herself do you know
01:28:29 do you know um it was only discussed um and the the the repairs and the contract management which isn't here i believe provided a verbal verbal
01:28:41 i believe provided a verbal verbal update
01:28:41 update on their position um and there would have been quite a wide-ranging discussion looking at the text under health and safety team did you write that text probably right it says the majority of
01:28:52 probably right it says the majority of the actions 28 which remain incomplete after 12 months relate to tentative flat entrance doors and or transom lights or side screens which have been highlighted as potentially not compliant in some cases doors have been changed
01:29:04 in some cases doors have been changed but assessor has requested confirmation that replacement doors are compliant with current requirements sometimes a temporary door has been fitted and never been replaced with a compliant door orders have been raised but have been
01:29:15 orders have been raised but have been abandoned sometimes due to non-access but no escalation has been undertaken so action remains outstanding did was was the tmos approach to
01:29:27 did was was the tmos approach to replacement of flat entrance doors uh what was the tma's approach to replacement of flat entrance doors identified by mr stokes as requiring confirmation of compliance
01:29:39 as requiring confirmation of compliance with current requirements um if what as and when doors were required they are required to meet the current standards so they should be an ft-30s self-closing
01:29:50 so they should be an ft-30s self-closing of d30s um in terms as part of his assessment he would identify doors which he was concerned were potentially non-compliant or he didn't recognize or they weren't in keeping with the
01:30:02 they weren't in keeping with the the others in the blog in this case it looks like the first thing we would do is check with other tenanted doors or leasehold doors um where they're tenanted doors we would try and get
01:30:13 tenanted doors we would try and get information from the repairs team when the door had been replaced can they confirm that it meets the current standards as you can see that wasn't always
01:30:20 always as easy as it should have been um if they'd been replaced because there'd been an emergency sometimes there would be a temporary door placed there
01:30:31 be a temporary door placed there for forced entry or whatever reason i think sometimes repairs weren't good about
01:30:38 about remembering to go back and replace with a fully compliant door so that would relate to some of them and then as you can see sometimes it was problematic to get access so orders were erased
01:30:50 orders were erased and then whenever i um went through the system and interrogated it in some cases there means a number of attempted access but then there was no escalation to the neighborhood team which is what should have happened um in order to to contact residents to
01:31:02 um in order to to contact residents to say look in terms of your tenancy it's really important that we get access and to explain um so although they sort of sit with me i'm
01:31:10 i'm going between repairs and the neighborhood team trying to make sure that those arrangements are in place um now you say there that orders have been raised but have been abandoned sometimes due to non-access but no escalation has been undertaken so action
01:31:21 escalation has been undertaken so action remains outstanding abandoned by whom um i think the repairs system why would it be why would the repair system abandon orders um
01:31:33 abandon orders um probably best to ask graham webb because he will understand the detail but i think there the process is that there'll be a certain number of attempts made and then wrongly in my view they would
01:31:44 and then wrongly in my view they would um then become abandoned what they should do is be escalated i think which is what i was trying to to get them to implement
01:31:51 implement escalated to whom well within the repairs team they should there should have been a way that they um
01:31:59 forgotten the term and a way that they they should have been able to like almost a jeopardy list i suppose is what i mean right why has that not taken place do you know i don't know sorry um i think it was only really in terms of when i was
01:32:11 only really in terms of when i was interrogating works orders that i had requested and couldn't confirm that they'd been complete that some of these things came to my attention and when they did i would speak to graham and his staff to see if we could look at more effective ways of of
01:32:23 look at more effective ways of of dealing looking at neighborhood management south the other uh area of breakdown just looking at the uh explanation there was that typical
01:32:33 typical of the kind of explanations that you received for a team's failure to close down an fra action
01:32:42 this is sometimes what we'd receive is it was a variety of things but yeah sometimes
01:32:46 sometimes can we then look at the minutes for the 13th of june 2017 at tm0100 five the day before the fire yes
01:32:57 five the day before the fire yes page one health and safety meeting 13th june 10 am barbara matthews is there janet you're there
01:33:06 there and peter madison is there and it's page three please
01:33:12 paragraph 3.1 fra actions bm expressed concern at the volume of actions which remain outstanding she emphasized the importance of completing these in a timely manner not least because they will continue to
01:33:23 not least because they will continue to be raised particularly as the fra reviews become more frequent given barbara matthews concern as recorded in the minutes up up to this time
01:33:34 to this time do you accept that there was still as at the
01:33:37 the day before the fire at least clearly an issue in terms of closing down actions in a timely manner my recollection is there'd been a tremendous amount of progress made but it was still um a position that we
01:33:49 but it was still um a position that we were pushing on to improve so yes there was there were still things that needed to be attended to
01:33:57 and at the time of that last meeting in june 2017 would you agree that the tmo had not managed to get on top of the number of outstanding by which i mean past due fra actions within its properties
01:34:08 within its properties certainly not completely no no can you explain why despite miss matthew's very clear call for outstanding fras to be closed out at a stubborn corpus of 12 months plus fra actions she was still
01:34:20 12 months plus fra actions she was still making
01:34:21 making that request at the time of the fire i mean i can't speak for others but i i know that some of the things which were down to the health and safety team are just as per the explanation and
01:34:32 are just as per the explanation and we've just discussed were really a challenge for me to get them progressed um um you know there were some some things right side of our control in terms of of access um and some there were systems
01:34:46 of access um and some there were systems in place for example the one that came to light about abandoning repairs that i wouldn't previously be aware of um i can't give you an explanation for other people's i only really know what the detail of of what i struggled
01:34:58 what the detail of of what i struggled with
01:35:00 with now we'll turn to specific implementation of actions at grenfell tower
01:35:06 tower in due course before we do that there are some preliminary questions about fras
01:35:11 fras [Applause] we know that carl stokes produced an fra fire risk assessment and an action plan for grenfell tower on the 20th of june 2016. that's at cst403069
01:35:25 that's at cst403069 did you know that the vast majority of the actions identified by carl stokes in the april 2016 fra for grenfell tower were identified as still presenting a
01:35:36 were identified as still presenting a risk in the 20 in the june version i think i was aware of that my recollection is that um we knew that we
01:35:47 recollection is that um we knew that we were going to instruct him to do um to carry out a fire risk assessment at the conclusion of the work and actually we instructed him to go in april
01:35:55 april so that we would partly so we would be identifying what information we required from the contractors before they left site because contractors notoriously when they leave site are a bit more
01:36:06 they leave site are a bit more challenging to get documentation from so it was it was partly um to identify what he was going to be needing in the june
01:36:13 june so i wasn't surprised that some of them were outstanding um but i don't know beyond that right and why were so many items identified by mr stokes in his april 2016 fra still outstanding as at
01:36:26 april 2016 fra still outstanding as at june
01:36:27 june um i i can't comment on on that without looking at the detail but as i say i do know that some of those um some of those documents wouldn't have been readily available i believe until
01:36:38 been readily available i believe until closer to completion of the contract on site but he was he was raising them in advance so that we knew we had to start hustling the project team and the contractors and whoever to provide them in in numbers terms did you know that
01:36:49 in in numbers terms did you know that there were 42 items identified in the april 2016 version which had not been cured as at june um i didn't know that in numbers
01:37:00 june um i didn't know that in numbers right given that all but three of the actions from the april 2016 have been assessed as high priority all but three and so should have been
01:37:11 all but three and so should have been rectified
01:37:12 rectified on your understanding within three weeks or there should have been all interim measures for them how come so many of those items had not been addressed before the 20th of june
01:37:23 been addressed before the 20th of june when he did his june fra um i can't give you an explanation um i i would reiterate that some of the documentation may not have been readily available until closer to the end of the contract
01:37:35 until closer to the end of the contract so some of that um uh some of the certification the regulation 38 information may not have been available um but i i can't um sorry without looking at the detail
01:37:46 looking at the detail no well let's try and work it through with a worked example in detail can we
01:37:53 can we can we look please at uh the 20 april 2016 record of significant findings and actions at seven three tm00 seven one
01:38:04 seven three tm00 seven one page seven
01:38:12 and if we look at item 19 b at the top of your screen there you can see that it's a red item high there are no operating instructions or as installed diagrams located next to
01:38:24 or as installed diagrams located next to the automatic opening vents control panel
01:38:27 panel how is this control panel accessed and the action is provide operating instructions and as installed diagrams located next to the aov control panel along with access information
01:38:39 access information and then action is clear w and then the last column we will be fitting a cover to aov pain and operating instructions inside with keys
01:38:51 with keys um and i didn't read the bit about ryden's in the middle column there to be fitting a cover um so that's that was the content of the april 2016 record
01:39:02 record significant findings and actions um we then
01:39:06 then look at uh the w-2 we can see let's look at that tm00873869 page two
01:39:22 it looks as if this outstanding item goes
01:39:25 goes on to w2
01:39:29 on to w2 uh as
01:39:33 item 19a
01:39:37 if you uh look at it's not a very easy document to navigate but do you see
01:39:51 i can't see a reference on it sorry my page number is right
01:40:01 i think the answer is there isn't anything on that until august 2016. okay but if you go um to page two i can show this to you if
01:40:12 to page two i can show this to you if you go
01:40:12 you go to the second box
01:40:19 and look at the second box top line
01:40:25 where it says process completed you see that wednesday 31st of august 2016. yes
01:40:34 can you explain why this item
01:40:39 uh and i'm afraid i'm not able to identify which the item is but you are able to identify why that only goes on there on the 31st of august 2016.
01:40:48 2016. no um no i mean i was seeking the information from claire williams who was clearly in liaison with ryden's about about providing
01:40:59 providing the documentation that's required and i can't give you an explanation other than i didn't receive confirmation until that time right right
01:41:10 right right and why did you consider that it was appropriate to leave items such as that without taking action at all for some four months
01:41:23 i wouldn't have taken no action at all i would have chased up claire repeatedly in the interim right she's relying on writings to provide the information and i'm in good faith expecting that any day
01:41:36 i'm in good faith expecting that any day unfortunately it looks like it did take a while to come through but it looked like it was going to be straightforward and it looked like it could be resolved quite swiftly right
01:41:51 it looks if you go to the bottom of the page there's a big blue arrow uh which is tell me how this works it looks as if this is a history starting at the bottom and there's a
01:42:02 and there's a a sort of monty python-esque finger coming out from the left-hand side i don't know what that indicates but process started cyril morris 10th of august 2016. hs fire risk assessment process started
01:42:14 hs fire risk assessment process started at stage initial and then you could see the dates going up
01:42:20 up the process completed at the end of august 2016. yeah that was that in relation to the april 2016 fra do you know all the or the june i think it would be june
01:42:31 it would be june right why did you say that well partly a conversation that you and i had earlier about
01:42:36 about the um the june items not making it on until
01:42:39 until august um but it doesn't it isn't clear from here i'm just going by what we discussed earlier let's look at the let's look at a different part of the of w2 tm0873842
01:42:52 of w2 tm0873842 this is your jw 10. okay
01:43:21 tmo double zero eight seven three eight four two
01:43:25 four two yes could you just explain what this document is um we thought it was w2 but is that right it's it's um yeah it's a download that i've got from w2 that i've conv you can
01:43:36 from w2 that i've conv you can you could do a conversion into excel so i've run the information from w2 and it's it's produced in an excel document right okay
01:43:45 and you can see there that the inputs on that page uh for uh
01:43:58 and the trouble is i can't navigate it to show you where it starts line 38 i think is what you yes 9 38 is the bottom 10th of august 2016. yes
01:44:07 yes uh 19 you can see 19c 19a uh is uh uh is item 37 which i think is what i want okay that's become 19a in the june version
01:44:18 version right uh and you can see that that's still outstanding um well my question is why was it only inputted on the 10th of august 2016 when it had appeared
01:44:30 10th of august 2016 when it had appeared in the june fra i can't give you an explanation for that that would that would be really unusual for us to to cause any delay because we always prioritized it do you remember whether mr stakes
01:44:41 do you remember whether mr stakes discussed with you the issue the items he had identified in his april 2016 fra action plan most of which or at least many of which were high priority reds had not been addressed by the time of
01:44:53 had not been addressed by the time of the june 2016 fra it's likely he would have done but i don't i don't request what did you tell him what answer did you give him um well i may well have i've run a report such as this and talked him
01:45:04 report such as this and talked him through what i knew had been completed and what um what i what i knew whether there were hold ups or delays or what i was imminently waiting to to have completed or he may have actually gone and spoken to claire
01:45:16 actually gone and spoken to claire williams because a lot of the issues obviously were inevitably related to the project
01:45:28 now
01:45:41 can i ask you please to go back to the
01:45:48 the fire safety question in 2013 uh and the discussion of the draft hodgson report in august 2013. this is tmo20899807
01:46:07 and i don't think i've shown you this before
01:46:10 before no you could see that it's an executive team meeting you're not present which is one of the reasons why i didn't haven't shown it to you before but if you go to the bottom of page one you can see 1.4 it says well then there
01:46:22 you can see 1.4 it says well then there was a lot of operational action in the report
01:46:24 report that's the hodgson report in draft it did not help us with the over the page organizational structure straight management peter madison was concerned that the fire risk assessments were substandard and could put the organization at risk
01:46:38 there was also some concern that high risk blocks were being classified as low risk
01:46:42 risk and vice versa just pausing there was that something mr madison ever took up with you
01:46:47 with you no never never right uh and then a little bit lower down it says it was agreed to set up a meeting with matt hodgson peter madison and janice ray to discuss the way forward
01:46:58 discuss the way forward peter had suggested he take on the responsibility for all areas including asbestos and fire risk which was still with with janice ray and janice ray would have a more strategic role and work with the fire brigade
01:47:09 brigade did such a meeting ever take place i've got no recollection of such meetings did a discussion even if not in a meeting ever take place between you peter madison and matt hodgson no
01:47:20 peter madison and matt hodgson no i don't believe so right and then it says the possibility of adrian bayman transferring to a r to be considered so that peter madison could resource this area of work
01:47:31 could resource this area of work governance would be the reorganized health and safety committee and also the a
01:47:34 a r health and safety group which sasser jevons would review and share herself matt hodgson's report to reflect this structure do you remember that discussion or any discussion on that topic with with
01:47:45 that topic with with peter madison or anybody else no the only um
01:47:49 only um thing that's i think relevant at this point is we discussed michael lyon's policy statement yesterday he did and his structure that he set out um may have had some bearing on this
01:48:00 um may have had some bearing on this this dialogue which i was unaware of did mr madison or anybody else raise any concerns with you about your capacity your capacity to manage fire risk no he didn't
01:48:11 didn't uh or or about the quality of mr stakes fras
01:48:14 fras no i'm really surprised to read that actually because i'm not aware that he asked to see very many of them um so i'm not sure he would have reviewed very many of the assessments themselves
01:48:25 themselves right so is your evidence that none of these suggestions were ever discussed with you let alone taken up definitely none of them were if you were discussed with me right
01:48:36 discussed with me right they weren't taken up can we go to
01:48:39 tm00849798 please
01:48:44 this is an executive team meeting of the 18th of september 2013 and for self-evident reasons you're not present but there's a discussion about the same topic if we go to page six please
01:48:56 second bullet point down we can see uh there's a discussion along the lines of clienting of fire risk assessments have been taken over by a r which were
01:49:07 have been taken over by a r which were due to be completed by mid-october were you aware of any plan for a r assets and regeneration to take over management of the fire risk assessment no did you want that to happen um i'd never
01:49:20 did you want that to happen um i'd never been
01:49:21 been consulted on that happening and wouldn't really be for me to to say had you been consulted would you want that to happen um i want it to happen i suppose from a health and safety
01:49:33 i suppose from a health and safety perspective i would have been concerned about that happening because the actions that were not being progressed swiftly enough all sat within um that division so actually if you put
01:49:45 that division so actually if you put everything in one division where there are potentially problems about getting things done in the right time frame then i didn't see that was a good thing necessarily i see peter madison confirmed that it didn't in fact happen
01:49:56 confirmed that it didn't in fact happen do you
01:49:56 do you do you know why it didn't happen no i i didn't know it was even discussed at this stage so sorry no no can we then go to tm00 856 238 please page two of this email run
01:50:08 238 please page two of this email run this is an email from you to anthony parks on the 31st of january 2014. we could pick it up just at the very bottom of page
01:50:18 page one where we can see your name as the outgoing
01:50:24 outgoing oh you've got yeah you can't quite see it well
01:50:27 it well it's just below the anthony from janice ray and then over to the top of page two to 31st january to anthony parks dear anthony attached as a copy of the fire safety policy that michael has drafted as an alternative to the one
01:50:38 has drafted as an alternative to the one which i recently consulted in and issued to the lfb just pausing there that must have been the november 2013 policy we saw yesterday yes yes yes this is based on michael's recommendation that responsibility for
01:50:49 recommendation that responsibility for fire safety in its entirety transfers to a
01:50:52 a r grateful if you could advise whether this is the way the organization wishes to go
01:50:56 to go uh now clearly you're referring to michael learns his alternative policy that you identified yesterday in your evidence aren't you yes that's right uh and
01:51:07 yes that's right uh and do you know why mr lyons had recommended that responsibility for fire safety should be transferred to assets and regeneration no i i didn't know if it was just him speculating about whether that would be a good
01:51:18 be a good a good way for the organization to go um having read the exact team minutes it may be that he's being briefed to reduce something of that that nature i don't know really
01:51:29 i don't know really going to page one would take this quickly given that it didn't happen uh on page one seventh of february 2014 park's
01:51:37 park's email to you janice i've reviewed the fire safety policies drive to my michael uh lay out of the policies clear etc etc and then he goes on to say however the
01:51:49 and then he goes on to say however the section on roles and responsibilities does not meet with the agreed policy to split the strategic corporate role from the operational role uh etc um and he goes on to say other things about about management
01:52:02 other things about about management structure as far as you know was mr parks objecting to the role of fire contract manager that he refers to
01:52:09 to um i i sort of yeah i mean it i took this to mean that this wasn't the way the organization wanted to go he didn't obviously give me any background about what discussions had
01:52:20 background about what discussions had taken place so so i didn't know if it was something that michael just came up with as a concept or whether it was he'd been asked to put something together and right if we then go to
01:52:32 right if we then go to to to the policy tmo one double zero four
01:52:35 four zero seven nine zero you can see we looked at this yesterday this is his draft fire safety policy dated january 2014.
01:52:45 2014. um we can see that you are identified there as the author together with him i don't think we looked at this version yesterday uh but uh was this the version that you sent anthony parks uh
01:52:56 that you sent anthony parks uh no i don't think so i think it was the other version right uh did have you ever seen this one before then i think we looked at this yesterday but and i must have seen it before but uh right uh the one i think we looked at
01:53:07 right uh the one i think we looked at yesterday with your name on had may in it but
01:53:09 it but no matter can we go to page six this is where i want to show you what it says and ask you about uh page six you can see under the third sub-header it says fire contract manager the fire contract manager will be tasked
01:53:21 the fire contract manager will be tasked with the strategic management of fire precautions within the responsibility of kensington and chelsea tmo reporting directly to the head of contract management and shall and you can see a list of things there
01:53:33 there formulate and revise tma's fire plan conduct and arrange audits to ensure that provisions within the fire safety policy are being enforced to the standard required ensure sufficient information instruction and training is carried out
01:53:44 instruction and training is carried out ensure that the fire precautions are maintained effectively investigate funds and introduce controls appoint a designated person etc etc uh this role of a fire contract manager
01:53:56 uh this role of a fire contract manager was that ever discussed at any meeting you attended no no did you ever have any discussions with anthony parks about that specific role
01:54:03 role no literally the email that you just showed is the only correspondence i had with anthony on the on the matter clearly if one goes to page seven that there's a distinction between the fire contract manager and the health and
01:54:15 fire contract manager and the health and safety manager was there any of it ever any discussion you were party to which uh involved the proposal that these two roles should be split no no there wasn't right
01:54:28 no no there wasn't right so your role included all of the majority of the responsibilities set out in the list for the fire contract manager we can see in mr lance's draft majority
01:54:37 majority yes i see was there a need in the tmo at the time for a person with specific responsibility for the management of fire risk or fire safety as opposed to health and safety more generally
01:54:48 generally um
01:54:52 it was all i mean we've discussed it several times there was a need for more resource whether it needed to be a separation of roles or just just a boosted resource and would have been a decision for somebody further more senior than right
01:55:04 somebody further more senior than right now we don't need to go to it but the later version of this document which i did show you briefly yesterday may 2014
01:55:11 may 2014 at tm00856458 there's a need to look at it had a section on roles and responsibilities but the role of fire contract manager had disappeared can you help us about
01:55:23 had disappeared can you help us about why it had gone i suspect i'd forgotten about this i suspect that um i may have doctored this document edited it and and thought of having a
01:55:34 edited it and and thought of having a separate fire safety policy statement done some work on it and then put it to one side and not gone back to it so i suspect that's what the one that you showed me is an updated version that i had worked on but was never adopted did you would you
01:55:45 never adopted did you would you er correct but did was it you who removed the proposal for a fire contract manager it probably was because by then it was clear that there wasn't going to be one i see so was it always your view that
01:55:57 i see so was it always your view that then they did not need to be a separate fire contract manager and that you could manage perfectly well within the umbrella of your work as the health and safety manager um as as i said i wasn't i wasn't consulted
01:56:09 as as i said i wasn't i wasn't consulted the only the only information i ever had about the suggestion was what came from michael lyons i took a view from anthony who was my manager and he sort of
01:56:20 my manager and he sort of dismissed it so so that to the best of my knowledge it wasn't even up for consideration or if it was i wasn't party to any any discussion so i didn't think it was realistically on the table
01:56:31 the table now i want to ask you some questions about deficiency notices procedure and process
01:56:36 process we've talked about closeout actions for fras i want to switch to the question same question but in respect of deficiency and enforcement notices from the lfb can we start with your july 2020
01:56:47 can we start with your july 2020 statement please at tm00-873799 page 18 paragraph 35 and you refer there to the procedure for dealing with
01:56:58 dealing with lfb deficiency notices and those particularly of january 2016
01:57:13 tmo double zero eight seven three seven nine nine
01:57:16 nine nine page eighteen paragraph thirty five
01:57:27 now in 34 you give the background the 17th of november 2016 notice of deficiency for grenfell yes we've had seven fire safety matters in it and then you
01:57:38 fire safety matters in it and then you say in paragraph 35 of relevance to this question is the tmo procedure for dealing with lfp deficiency notices dated january 2016 which set out the following
01:57:49 following depending on the nature of the breaches the h s team will send a copy of this notice to the relevant teams and discuss with them the necessary remedial action and time scale for this h s team monitor completion of the
01:58:00 h s team monitor completion of the necessary works deficiency notices and broadly compliant letters and progress with completing the actions they raise are reported to the health and safety committee further a summary of these are provided in the company's annual
01:58:11 provided in the company's annual health and safety report
01:58:16 let's look at the document itself this is a tmo
01:58:19 is a tmo double zero eight four zero four eight zero
01:58:31 and it's paper three so it would have been produced to a a meeting and we know that it was in fact was in fact produced at the january 19th of january 2016 health and safety
01:58:42 19th of january 2016 health and safety committee meeting we'll look at the minutes of that in a moment just looking at this document did you draft this yes you did what prompted you to draft it um
01:58:52 it um actually i think it was a request by peter madison it reflects the process or the procedure that we were following but we had never documented it and it seemed sensible right now this is january 2016
01:59:10 and do you recall that the adair tower enforcement notices had come in the month before yeah december and january indeed were they a prompt for the production of this document
01:59:21 production of this document no not really because they're talking about deficiency notices the enforcement notices were treated entirely differently did you receive any help in drafting or finalizing this policy unlikely right
01:59:35 did you ask the lfbs fire safety team to consider it or approve it or review it in any way no because generally fire brigade had been
01:59:45 been pretty low key about deficiency notices they saw them as being non-statutory notices
01:59:49 notices um often the the defects that they were identifying they they felt themselves were relatively minor deficiency notice they didn't require any formal sign off um i would feedback to them often
02:00:01 um i would feedback to them often on progress at liaison meetings but they would rarely ever seek an update um now let's go to the minutes of the meeting tmo100 tmo10012670
02:00:16 19th of january 2016.
02:00:21 you're there if we go to page four we can see it paragraph 3.7 that it says jw summarize the process for deficiency notices set out in paper three to reiterate
02:00:34 set out in paper three to reiterate these tend to be received by jw are brought to this committee and are circulated to the teams with actions and time scale for completion pm requested a copy of any deficiency notice where defects related
02:00:45 notice where defects related to the work of his team did you get any feedback at this meeting about this policy
02:00:52 no i don't believe so did you usually provide copies of the deficiency notice to the relevant teams as requested by peter madison for his team yes
02:00:59 team yes um and that is exactly the procedure that we've documented is is when on receipt of the um of a deficiency notice we would allocate the work
02:01:09 work email scan a scanned copy to the individual and ask them to to advise us right progress what was the policy adopted formally or approved for me at this meeting yes then let's go back to the policy
02:01:23 yes then let's go back to the policy tm00840480 if we go to the heading progressing issues by lfb item 4 towards the bottom of your screen it says the fire safety team will generally
02:01:34 the fire safety team will generally telephone the tmo health and safety team following their audit to raise queries request confirmation of maintenance arrangements a copy of the fire risk assessment and to outline any breaches they will confirm if it is their
02:01:45 they will confirm if it is their intention to issue a notification of fire safety deficiencies or alternatively if they intend to send a letter confirming that they considered the block
02:01:52 the block to be broadly compliant with no statutory breach at the time of the audit
02:01:57 audit when a notice is issued a paper copy is sent by post for the attention of the health and safety team depending upon the nature of the breaches the health and safety team will send a copy of this notice to the relevant teams and discuss with them the
02:02:09 relevant teams and discuss with them the necessary remedial action and time scale for this hms team monitor completion of the necessary works now did the fire safety team from the lfb generally telephone the tmo
02:02:21 lfb generally telephone the tmo following their audit to raise queries and ask for confirmation of maintenance arrangements often that is the case yes would you usually provide them with confirmation um yeah i mean i would try and and
02:02:33 um yeah i mean i would try and and provide them with whatever it is they've requested so they asked for the first assessment we'd send that if they asked for maintenance um documentation i would speak to the compliance team a contract management team and get what
02:02:44 a contract management team and get what they required and email it to them as soon as i could right and and it says here that they would outline any breaches so would they discuss was this the policy that they would discuss each of the breaches with you
02:02:55 discuss each of the breaches with you um generally when they telephoned they would say oh we've been to this block because
02:02:59 because we often didn't know in advance where they'd be attending um i've used this book today and um it was generally okay but we had one or two concerns
02:03:07 concerns um and i'll email you separately but this is what but in the meantime could you confirm and sometimes it was just information that they needed which allowed them to to complete their audit because i think it's all kind of
02:03:18 because i think it's all kind of numerical and at the end it decides whether a deficiency notice is going to be served or not once you've received a notification of safety deficiencies the procedure notes that the h s team
02:03:29 the procedure notes that the h s team would send a copy of the notice to the relevant teams and discuss with them the necessary remedial action and time scales for this h and s team who does that refer to me right okay and adrian bowman and you
02:03:42 me right okay and adrian bowman and you and when you discuss timescale for completing the action how did you determine
02:03:45 determine what the time scale should be um it depended on the nature of the of the breach really um if it's um something that's really should be fairly straightforward if it's
02:03:56 fairly straightforward if it's communal storage or or anything of that nature i would be asking the um state services team leader to ensure that it was turned around in 24 hours 48 hours if it possibly could be and
02:04:07 be and and also that the the code take could go and esa
02:04:10 and esa go and speak to the resident and explain why it's important you know not to happen again um if it's more complicated um i think if if it's for example at least hold a door that's potentially
02:04:21 hold a door that's potentially non-compliant that's much more challenging um for because because it's demise to the resident and we've never yet kind of got to stage where we had successful enforcement positions so we
02:04:32 successful enforcement positions so we would be
02:04:33 would be looking for the home ownership team to start engaging with that resident but that's more difficult to quantify i mean it would it's clearly urgent but we would have difficulty
02:04:44 urgent but we would have difficulty turning it right as quickly as we would wish
02:04:46 wish how well um the deficiency natives had sorry the deficiency notices had their own deadlines in didn't they yes often six months well why not use those
02:04:57 often six months well why not use those well yeah but and clearly i would have used those but um some things can be done in a few days and so i want them done in a few days i'm not going to wait until you know that there's um that's that's the
02:05:08 that there's um that's that's the cut-off period for the deficiency notice but anything that we can and should do more swiftly than that then that's what we would try to do now the procedure says as i've shown you
02:05:19 now the procedure says as i've shown you that deficiency notices and broadly compliant
02:05:23 compliant in fact i haven't shown you this i should read it out deficiency notices and broadly compliant letters and program and progress with completing the actions they raise are reported to the health and safety committee further a summary of these are
02:05:34 committee further a summary of these are provided in the company's annual health and safety reports that's what the procedure says um if we just go next to your july 2020 statement paragraph 36 just below where we were
02:05:46 paragraph 36 just below where we were reading
02:05:46 reading gmo double zero eight seven three seven nine nine page eighteen paragraph thirty six you say there
02:05:53 there this procedure therefore required the tma to monitor completion of the necessary works and progress actions through the health and safety committee but it did not specify that these actions be closed out using the same
02:06:04 actions be closed out using the same recording process or systems as the fra program
02:06:08 program it is for this reason that progress made by the tmo in closing out the actions raised in the above nod notice of deficiency was monitored in health and safety committee at lfb and tmo bi-monthly meetings
02:06:19 at lfb and tmo bi-monthly meetings following its receipt rather than being closed out through w-2 or crm
02:06:24 or crm this is recorded in the following meeting minutes and reports now uh you and you you exhibit some so in summary does it does it tell us that the tmo
02:06:37 does it does it tell us that the tmo essentially had two systems running in parallel
02:06:39 parallel one for closing out fra actions via w2 by this stage certainly w2 and secondly complying with deficiency notices by
02:06:50 notices by way of monitoring through the health and safety committee and by monthly meetings with the lfb yes right largely because sorry just to say largely because we actually didn't receive very many deficiency notices so
02:07:01 receive very many deficiency notices so we had never created a dedicated workflow
02:07:04 workflow um however at by the time the fire happened i'd been thinking we could set one up on crm because it was much more straightforward we had access to a system sorry to interrupt you so does that mean that you didn't input
02:07:16 so does that mean that you didn't input the actions that were required as a result of a deficiency notice into the w-2 system so that you could monitor it no we didn't why was that it just wasn't set up
02:07:26 set up in that way and we as just reiterate we actually generally didn't get very many of them and some years we might have two some years we might have half a dozen
02:07:35 dozen but um and often there would only be two or three actions so it was relatively straightforward to keep on top of them in in the way that i've outlined was it your decision when you drafted this
02:07:46 your decision when you drafted this policy
02:07:47 policy not to amalgamate the two streams um well it went to health and safety committee
02:07:55 committee for discussion and for approval so if anyone else could have said i feel strongly that we should be to be doing that i don't i don't think it was my decision it was the policy the procedure was
02:08:06 it was the policy the procedure was something that i drafted for discussion um but everybody had buy-in into it why did you decide that the actions required through a deficiency notice were not to be monitored through w-2
02:08:19 oh as i said we didn't get very many we would have had to have a specific workflow we knew that w-2 was coming to the end of its life and we were moving across to a different software um system and at that point
02:08:33 software um system and at that point i think we would have got to the stage of thinking actually let's set up a simple one in that um does this mean you didn't in fact use any electronic records or automated systems at all to keep track of the necessary actions required
02:08:47 of the necessary actions required by the lfb and their deficiencies yes that's probably true how were you able to to monitor progress and completion of those actions if you didn't use an electronic workflow well in the years when we had
02:08:58 workflow well in the years when we had two a year it wasn't really a big ask and they sat at the top of my entry and i would ring the relevant people on a regular basis or go and speak to them and if if we were starting to get more
02:09:09 and if if we were starting to get more of those um then that would have pre-empted what exactly what you're suggesting that we would have had an electronic system let's see how it was done then um let's take the grenfell deficiency notice of
02:09:21 take the grenfell deficiency notice of the 17th of november 2016 uh which you exhibit at paragraph 38 of your statement on page which we don't need to look at but let's
02:09:33 which we don't need to look at but let's look at the document it's tmo
02:09:36 00873834
02:09:41 and you can see there that it's got manuscript on it with updates added feb 17 is that your handwriting it is yes right
02:09:54 and if you scroll down please to page five you can see the schedule
02:10:05 yeah uh and again is that your handwriting it is yeah so just help us is it right that although the actions are arising from the notice were progressed uh
02:10:19 it was progressed in in this way you would simply write on the document in this yeah on this occasion or i would i would write on a separate document and append it to it um it depended
02:10:31 it um it depended and then where would you put it it literally would sit in the top of my entry i didn't have much paper by that stage so they were um how would you monitor how would you keep up with monitoring and making sure you knew what progress
02:10:43 and making sure you knew what progress was happening as i say we literally did not get very many of them i was always seeking to give feedback to the tmo lfb liaison meeting which was every two months
02:10:53 months so as a minimum i was going to be ensuring that i'd been through and identified what was going on so that i was
02:10:59 was able to update them right just just help me then look at article 11 item one you've written under actions to be taken neighborhood team instructed to treat
02:11:08 treat as zero tolerance items removed and regular inspections ongoing when were the neighborhood instructed to treat a zero tolerance um i had
02:11:19 to treat a zero tolerance um i had written two uh was it nikki it was probably nikki at that stage and provided her with a copy of this and said
02:11:27 said this is what we need to do going forward and she must have confirmed that that was the case i mean if three weeks later you wanted to find out remind yourself when you had given
02:11:38 out remind yourself when you had given these instructions to the neighborhood team you take this document off your of your pile on your desk what would you go to to work out when you had given those instructions
02:11:50 those instructions um well
02:11:53 um well the updates are added here on the 17th of february so uh i would work on that basis what would you how would you find out when you had instructed the neighborhood
02:12:05 when you had instructed the neighborhood team
02:12:06 team i would probably have an email stored somewhere that i would um that i would access but but i would have received confirmation pretty swiftly because this is something that they they should adopt immediately
02:12:18 that they they should adopt immediately right
02:12:32 um now you [Applause] say in your
02:12:41 june 2020 statement let me say show this to you tmo double zero eight three page 17 paragraph 70.
02:13:06 that i've been asked to confirm whether the spreadsheets used to track fra actions were generated using w2 or crm
02:13:13 crm as stated above i used a workflow on w-2 to allocate and track progress with the actions
02:13:18 actions up until a week or so before the fire crm was being introduced around this time
02:13:23 time and the intention was to close out old actions on w-2 and log new actions on crm
02:13:27 crm the new systems may have had slight differences however in my view they were both effective at tracking progress and identifying outstanding actions while reports produced from these two systems may have looked slightly different in substance they were no
02:13:38 different in substance they were no different
02:13:40 different given that you discovered i would all consider that w2 and then the successor system crm is efficient
02:13:47 efficient what was the point of having a policy which you drafted and which was then adopted which did not include monitoring deficiency notices using either w-2 or crm
02:13:58 either w-2 or crm was it just the sheer
02:14:01 low numbers um yes um but why give yourself the extra work can i just say that it sounds really straightforward but in order
02:14:12 but in order to get a workflow a dedicated workflow on w-2
02:14:16 on w-2 it means going through a load of hoops with the it team it's it's not straightforward and it would have they would have had to put something together for me to trial it wouldn't have been a sort of quick fix um
02:14:27 fix um we were having very low numbers and i also knew that w2 was getting to the end of its lifespan so in my mind i had thought once crm is on board that may be something that
02:14:38 is on board that may be something that it would be sensible to have a workflow which is much would be much more straightforward to put together um but yeah it was a combination of the two i felt like what we were doing was working we were getting low numbers
02:14:49 getting low numbers and we sort of had a view that going forward it's something that we could we could do differently and we could monitor more rigorously but at this stage we didn't feel like we needed to now you've suggested in your witness statement
02:15:00 witness statement your uh your july 2020 statement that the health and safety committee and the lfb bi-monthly meetings would be the fora in which deficiency items would be monitored
02:15:10 monitored and would progress on actions in deficiency notices become standing agenda items for the bi-monthly meetings probably not standing agenda items it probably as i say the brigade hardly ever
02:15:20 ever actually sought out an update on deficiency notices i probably would have given them some verbal feedback um and probably it should have been a standing agenda item but i'm not sure it made it
02:15:31 made it right did that mean that it would be up to you to report the progress that has been made in actioning the items raised on an ad hoc as and when basis usually yes yes i'm going to change to a
02:15:42 usually yes yes i'm going to change to a completely different topic now uh mr chairman i i i there's a possibility i could cover it in 10 minutes
02:15:49 minutes but it may not be the case how are you getting on generally you can have a bid for it well is the answer i mean that answer suggests that we might
02:15:58 might give ourselves the indulgence of an early afternoon well yes i'm happy to take the chance as long as that's noted as a credit in my favor what about mine sorry i think i'm more
02:16:11 what about mine sorry i think i'm more concerned about the credit uh fastest raise concerns yes all right you probably had enough of the day if you get the chance to stop now haven't you um
02:16:18 you um yeah i don't i don't mind actually i can't i can hopefully do another ten minutes
02:16:22 minutes we've only got five minutes or so to go so now we can we'll stop at that point all right well as you know we're going to have to ask you to come back again tomorrow for more questions so yes i'm sorry about that so we'll
02:16:33 so yes i'm sorry about that so we'll resume
02:16:33 resume at 10 o'clock tomorrow please and as before please don't discuss your evidence or anything to do with it with anyone while you're out of the room okay all right all right thank you very much we'll see
02:16:44 all right thank you very much we'll see you at 10 o'clock tomorrow okay thank you
02:16:46 you thank you
02:16:55 thank you very much 10 o'clock tomorrow
02:17:22 you