Robert Black (TMO CEO) gives evidence on fire safety maintenance failures. Confronted with Salvus 2009 recommendations that weren't implemented, LFB deficiency notices showing 25% of AOVs not working, and the conscious decision not to develop personal emergency evacuation plans (PEEPs) for vulnerable residents.
00:00:22 would you ask mr black to come back in
00:00:28 please
00:00:47 all right mr black yes ready to carry on yes yes
00:00:51 yes yes thank you mr chairman yes um i'd like to ask you now about another aspect of oversight required by the rro and that is the maintenance of fire safety systems can we start please by looking again
00:01:02 please by looking again at the salvus assessment of tmos fire safety procedures in september 2009 at sal 13 sal 6013 and let's go straight to page
00:01:13 sal 6013 and let's go straight to page five in that we've looked already at paragraph one point two lack of or lack or inadequate tmo policy and arrangements uh and you can see from the uh
00:01:25 uh and you can see from the uh uh in the second italicized photogra uh paragraph i read to you earlier um that it refers to maintenance no specific policy and arrangements for
00:01:36 specific policy and arrangements for etc maintenance you see that [Applause] and it recommends uh underneath that that there'll be a specific policy developed
00:01:47 there'll be a specific policy developed for maintenance of all fire safety measures including those provided to assist firefighters now um was a policy developed in accordance with that recommendation i can't recall at this moment so
00:02:01 i can't recall at this moment so right and then page 11 action point at point 8.1
00:02:11 that is not uh the hazard is lack of inadequate coordination and cooperation with other responsible persons sharing same buildings and it says there does not appear to be any formal procedures in place to
00:02:23 any formal procedures in place to cooperate with any other responsible persons sharing the same building with tma properties to ensure that fire safety arrangements are effectively coordinated and that appropriate fire safety measures are in place and maintained in good order
00:02:34 good order and then if we go to page 18 in the action part of this document at 0.9.3 you can see that it says there
00:02:49 at 9.3 on page 18 it is strongly recommended note the word strongly do you see strongly recommended that tmo consider development of formal procedures uh to deal effectively with fire safety
00:03:01 uh to deal effectively with fire safety issues associated with disabled or vulnerable tenants and leaseholders and also any employees and then it goes on
00:03:12 to deal with that now um do you know whether uh the recommendation that the tmo introduced formal procedures to secure effective cooperation with any other
00:03:23 effective cooperation with any other responsible person sharing the same building
00:03:25 building with tma properties was was ever carried into effect i'm trying to remember which building would be where we had someone else into it
00:03:36 it in terms so
00:03:43 most of the in terms of the properties there were rbkcs
00:03:48 rbkcs [Applause] do you remember whether such a policy was ever introduced
00:03:58 by again i can't recall
00:04:02 let's look back then at the tma fire safety strategy of november 2013 at tm00830598
00:04:13 which is a document we looked at together before this morning uh and uh if you uh just have that on the screen in front of you there uh would you agree just before we look
00:04:24 uh would you agree just before we look at it in detail that one would expect to see this document define the processes that the tma would have in place to provide a system of maintenance for fire safety measures
00:04:35 for fire safety measures yes a in terms of management of contracts to manage them yes
00:04:42 yes yeah you've just in general terms do you agree that you would expect this document to define the processes that the tmo either had in place or
00:04:53 that the tmo either had in place or ought to have in place to provide a system of maintenance for all fire safety managers so we would have a system in place for all equipment within the tmo i'm again i'm not sure
00:05:05 within the tmo i'm again i'm not sure whether there was an overall policy right
00:05:09 right well let's see how we go do you agree that we've well have you seen any trace of any
00:05:18 any attempt to develop a fire safety strategy for the tmo between september 2009 and the salvos fire safety management report of that that month
00:05:29 that that month and janice ray's first attempt in january 2013 which led to this document in
00:05:34 in november 2013. i haven't seen another document i would know that in terms of asset management and contract management which managed
00:05:46 and contract management which managed the stock so outside the house and management you'd have we have a team or had a team of engineers and people who'd managed contracts which included fire safety equipment yeah but do you agree that in a nutshell despite
00:05:58 do you agree that in a nutshell despite the salvus recommendation in september 2009 the tmo never developed a maintenance strategy for maintaining all of its active and passive fire safety measures
00:06:09 safety measures between 2009 and 2013. i think asset management had a strategy for managing their responsibility for managing the stock
00:06:18 stock through their asset management contract yes but i'm talking about an overall fire safety strategy do you accept what i'm putting to you i accept that yes thank you now um can we go to paragraph 1.1 in this
00:06:30 can we go to paragraph 1.1 in this document
00:06:32 document it says as acknowledged in the tmo health and safety policy statement the company is fully committed to providing a safe and healthy environment for residents employees and contractors the area of fire safety in particular is highlighted
00:06:44 fire safety in particular is highlighted as being of significant importance in a residential setting and as such is an area which is subject to intensive inspection maintenance and assessment activity
00:06:55 maintenance and assessment activity do you accept that the clear intention here as expressed by the tmo is to have an intensive maintenance regime
00:07:04 yes yes now if you look at the second bullet point uh on page two at the bottom of this document
00:07:16 of this document this is management arrangements for fire safety 5.1 this includes but is not confined to the following first bullet point is program of regular estate inspection and then over the
00:07:27 estate inspection and then over the to the top of page three second bullet point
00:07:31 point inspection testing and maintenance of all fire safety systems stroke plant strike equipment as per the requirements of the relevant british standard by competent contractors under a planned
00:07:42 competent contractors under a planned preventative maintenance regime in the case of emergency lighting the maintenance contractors regular checks are supplemented by monthly inspection and testing by the estate staff records
00:07:53 and testing by the estate staff records are maintained of these checks would you agree that that that reads as a policy objective as opposed to
00:08:03 to processes governing how those objectives would be achieved yes yes i mean for example there's no description here of what the planned preventative maintenance regime would actually entail is there
00:08:14 actually entail is there no no and there's no comprehensive list is there of the fire safety measures that would be subject to a preventative maintenance regime
00:08:23 regime no no said that therefore there's no mention of smoke control system needing to plan preventative maintenance or or anything of that nature is there we don't see that not there no no no no i think do we see
00:08:36 no no no no i think do we see any list of the british standards to which the systems would be maintained is that right well i can't see it there but that doesn't mean we'd be in the contract
00:08:44 contract no and there's no document there's no reference to any procedure documents which would set out the fire safety measures
00:08:50 measures uh governing maintenance we don't see that detail either here no i can't see the detail or how maintenance records would be stored there's nothing about that
00:09:01 there's nothing about that no no can you explain why this fire safety strategy didn't didn't mention those things
00:09:10 i i think in sense when we look at contract management and maintenance so this is an overall strategy so if you follow the line through to asset management investment and contract management
00:09:21 investment and contract management that's where the details would be in terms of actually how they let contracts highly manage the contracts to what detail in the contracts were doing in terms of
00:09:32 the contracts were doing in terms of inspection i think that's where the detail would be so you'd find the detail of the processes in individual contracts with individual contractors but not as part of the fire
00:09:43 contractors but not as part of the fire safety strategy itself is that right i think so now it's slightly changed because this is 2013
00:09:51 is 2013 2013. so i think the issue we had is a lot of time between 2009-2013 a lot of the information was held in spreadsheets and not in a sort of one
00:10:04 spreadsheets and not in a sort of one area development sorry
00:10:09 would you agree that if any provisions directions guidance relating to planned preventative maintenance was set out
00:10:20 set out in the individual contracts between the tmo and individual contractors that wouldn't amount to an overall policy would would it no no and if somebody wanted to know the answer to the question
00:10:31 answer to the question what is the tma's policy on routine and regular maintenance of for example all of its aov systems what would it
00:10:42 all of its aov systems what would it what would the tmo point to
00:10:46 point to i imagine that would be at the local level
00:10:51 level not an overall strategy right you say can we then look at tmo double zero eight seven three three nine eight and i'm going to show you here
00:11:01 you here a report
00:11:06 by matthew hodgson entitled safety management review dated september 2013 marked for your attention
00:11:17 september 2013 marked for your attention now uh what i'm showing you here is the final draft of september 2013. we'll look at it in a little bit of detail in a moment it's a review by matt hodgson a health and safety professional done in that
00:11:28 and safety professional done in that year
00:11:29 year did you commission that report uh anthony parks did why did he do that so what we had was a an atmo audit of health and safety the auditors
00:11:40 auditors we had three levels of audit say unsatisfactory saturate satisfactory and substantial the order uh covered health and safety the audit came back as uh
00:11:51 the audit came back as uh i sort of forgot my wording again i think limited assurance limited assurance thank you and because of that so within our processes limited insurance would mean
00:12:02 limited insurance would mean that we have to have a substantial action plan and after a discussion with anthony we decided to anthony decided to bring in this individual to carry out review to
00:12:14 this individual to carry out review to help us
00:12:15 help us improve the outcome of the next audits of that area which would plan i see so in a nutshell mr park's commission this review in response to a recommendation made by rbkc's
00:12:28 a recommendation made by rbkc's audit in the april of that year which resulted in the limited assurance yeah yes yes okay now um as i said as i say this is the final draft of the final version of september
00:12:40 draft of the final version of september 2013. if we can go to page one we see it's marked for your attention can we assume from that you read it when you received it yes yes um can we look please at page 19.
00:12:58 health and safety procedures and it starts
00:13:01 starts by saying there is a policy arrangements section
00:13:05 section in the kctma policy however it does not adequately detail what risks the business is exposed to and lacks the finer detail to explain exactly what processes risk assessments produce standard checks
00:13:16 risk assessments produce standard checks and tests best practice inspections etc should be implemented in order to fully meet the statutory and mandatory obligations in relation to the plant and equipment
00:13:24 equipment under kctmo control across the estate the following issues require attention there are only a handful of arrangements in the policy many are missing for example pressure vessels working at height contractor
00:13:36 vessels working at height contractor management etc and many of the fire arrangements have been bunched together and by doing so lack the detail in relation to what the planned
00:13:42 planned preventative maintenance process should look like eg all fire protection systems recorded together
00:13:49 together now as you can see mr hodgson makes uh the same point about lack of adequate detail regarding plant and equipment that salvas had made in 2009. that's right isn't it yes yes and and
00:14:00 that's right isn't it yes yes and and certainly a lack of any detail about what planned preventative maintenance should look like do you agree
00:14:05 agree yes uh so when you read this were you not surprised to see that the salvos recommendations from 2009 had still not been implemented um almost four years on yes did you investigate the reasons for
00:14:17 yes did you investigate the reasons for why that
00:14:18 why that that had happened or not happened i i spoke to sassa germans who this within the
00:14:25 the higher era and it would have been under marcon
00:14:28 marcon anderson who was the asset manager at that time uh and what did they what did you say you spoke to them did you challenge them did you say
00:14:37 you say now look here i want to know why this hasn't been sorted out in four years yes you did and what did they tell you they said
00:14:45 they said uh in the sense that a lot of the contracts were having to be renewed or we were feeling contractors so it wasn't a positive message which is
00:14:56 so it wasn't a positive message which is why we got a limited assurance
00:15:06 did they was there was this exchange in writing at all or was it was it face-to-face face-to-face right do you remember when that exchange took place probably when this came out right so
00:15:17 probably when this came out right so again all these wood reports would go to board so in sense they're not staying and sitting with me they'd be they go through a formal process to a finance audit and risk committee
00:15:29 to a finance audit and risk committee partner board and this would go to the board as well i did it do you remember we'll come back to that then later if we continue with this page of this document
00:15:40 continue with this page of this document and look at the fifth paragraph down under the heading health and safety procedures it says this the policy arrangements refer to the purpose of this procedure is to identify the action to be taken by the
00:15:51 identify the action to be taken by the tmo following a report of a breakdown or malfunction and that's in quotations this is a reactive approach to hns when the real purpose of effective policy arrangements is to clearly define the planned
00:16:02 is to clearly define the planned preventative maintenance regime that should be followed to cover statutory and mandatory processes to keep the stock operating effectively and safely i.e about compliance and not breakdown now do you agree that mr hodgson is
00:16:13 now do you agree that mr hodgson is making it clear here that the tmo have a reactive approach to maintenance
00:16:20 i wouldn't accept that wholly i we accepted report there were contracts in place to put with within the contracts team to manage the stock
00:16:32 if it's reactive then see the trouble is i think why i had a mixture of contracts at different ages here
00:16:39 here as well so i it's hard i just have to accept it
00:16:43 accept it right and you accept no doubt his recommendational statement that the tma needs to move to a system of compliance rather than breakdown by breakdown
00:16:54 breakdown yeah yes now let's look at page 20 his recommendations under item 4 on that page in the box you see that he he says carry
00:17:05 in the box you see that he he says carry out a full review of the property policy arrangements to ensure that there is a section for each property risk and for each subject the following is covered legislative requirements statutory and mandatory requirements to fulfill the planned preventative
00:17:17 fulfill the planned preventative maintenance process to achieve full compliance what records must be maintained and where
00:17:22 where you see that yeah now was a full review of the property policy arrangements actually carried out it would have been carried out in terms of the asset management team under peter madison
00:17:33 management team under peter madison uh peter sort of uh in terms of i think he just joined not trying to remember the date january 2013. so he'd only been impulse a couple of months i think
00:17:45 of months i think and so he then put in train a series of actions to address this by changing his team for one so he brought in alex boseman who then took on a key role
00:17:59 alex boseman who then took on a key role in putting into place certainly around the making sure all our records were in one place because that was a big weakness of the order
00:18:10 was a big weakness of the order a lot of the wreckers still were held in different places so using keystone to develop keystone fully for our contracts yes were only new policies introduced
00:18:22 i sorry i can't remember i do know whether any existing policies were changed
00:18:31 i can't remember a problem you can see his next recommendation number five ensure
00:18:35 ensure only qualified individuals are involved in the creation and updating of policy arrangements do you know whether that was done
00:18:47 [Music] i can't recall do you know how
00:18:53 the tmo would take any steps to ensure that only qualified individuals were involved in the creation or updating of policy arrangements that would one sense of peter would have had to
00:19:03 to review his team and and ensure that happened
00:19:07 happened do you know where the newly qualified do you know whether any new qualified individuals became involved i i know alex boseman came in as a key person within his team
00:19:18 person within his team to oversee changes was that as a response to this recommendation yes can we then look at a notice of deficiency uh issued by the lfb and respect of
00:19:29 uh issued by the lfb and respect of grenfell tower itself in march 2014 at lfb 6068. now the date
00:19:40 the date is the 24th of march 20 uh 2014 as you can see and it's addressed to the company secretary of the tmo
00:19:49 um a matter of chronology i think you're bound to accept that this is within a few months of the final version of the hodgson report in september 2013. yeah
00:20:02 september 2013. yeah if we go to the to page three please we can see the schedule and look at article 11.1 or 11 bracket 1 in the box in the schedule please it's
00:20:13 in the box in the schedule please it's the first item and the area of concern is expressed to be as follows failure in the effective monitoring of preventive and protective measures for example a significant number
00:20:24 for example a significant number approximately 25 percent of automatically opening events within the common parts of the premises were found
00:20:29 found not to be in working order no suitable system of monitoring was in evidence to identify deficiencies with the smoke ventilation system and then steps considered necessary to
00:20:40 and then steps considered necessary to remedy
00:20:41 remedy the contravention implement effective monitoring of preventive and protective measures you see that yes so we can see from that that in march 2014 nearly a year
00:20:53 2014 nearly a year after the hodgson recommendations from july that year and then in in final form in september 2013 there are still serious problems with the tma's preventive
00:21:04 problems with the tma's preventive maintenance aren't there there appears to be yes
00:21:06 to be yes why was that
00:21:09 i i don't have the detail here i mean this would have been sitting with contracts within the asset management and in the sense their
00:21:20 in the sense their contractors should be addressing this
00:21:23 yes i mean you see we've had a limited assurance result of an audit in april 2013
00:21:30 2013 we've got the hodgson review as a response to that which reports in july in draft in final form in september 2013
00:21:41 form in september 2013 and yet here we are in march 2014 with the lfb issuing you with a deficiency notice in respect of grenfell tower saying that there's been a failure in the effect of monitoring of preventive
00:21:53 the effect of monitoring of preventive and protective measures how come well obviously were fair to implement the recommendations but did you look into that at the time at this time yes uh i would have spoken to janice
00:22:07 uh i would have spoken to janice and sasha to find out what was happening
00:22:11 and if you look at the bottom of well sorry the next box down area of concern failure to ensure that any premises and any facilities equipment and devices are maintained in an efficient state in effective
00:22:22 in an efficient state in effective working order and in good repair and then there's a passage about emergency lighting luminaires and then underneath that approximately 25
00:22:31 25 aav ventilation units within common residential lobbies were not held in the closed position indicating the system has not been maintained in effective working order recommendation ensure that adequate
00:22:43 recommendation ensure that adequate maintenance systems are in place to ensure that the premises in any facilities equipment and devices are maintained in efficient to state if in effective working order and in good repair
00:22:53 repair so you can see again that there were serious problems with the aov and emergency lighting so far as maintenance regime was concerned yes yes except that and again that would
00:23:04 yes yes except that and again that would demonstrate wouldn't it that there had been a
00:23:06 been a a substantial or significant failure even in march 2014 to carry into effect uh the uh recommendations uh of of salvas from 2009 and again from
00:23:19 of salvas from 2009 and again from hodgson in mid 2013.
00:23:23 mid 2013. yes yes
00:23:26 and there are others article 21 which is about employees receiving adequate training at the bottom of that page and then over on to
00:23:37 and then over on to the next page
00:23:41 um i think you accept that the tmo had heard all this before at least twice
00:23:48 do you accept that had the tmo taken the advice it had been given in 2009 and again in 2013 it would would have prevented this notice of deficiency being served yes if we'd done a job properly yes now
00:23:59 yes if we'd done a job properly yes now do you accept that this notice of deficiency is serious because it's the lfb as enforcing authority
00:24:06 authority telling the tno as a responsible person that the tmos systems at grenfell tower put it in breach of its statutory obligations yes and that could result in a criminal
00:24:17 yes and that could result in a criminal prosecution of the tmo couldn't it yes and more importantly have fatal consequences for the residents
00:24:22 residents yes do you accept that your role as chief executive officer was to make sure that the tma's management and maintenance procedures first of all were adequate yes yes and
00:24:33 first of all were adequate yes yes and second
00:24:33 second implemented effectively yes and do you accept that you fail to fulfill your role in those respects in terms of my rule yes yes let's turn to a different topic vulnerable residents now uh do you
00:24:46 vulnerable residents now uh do you recall that the question of persons especially at risk was brought to your attention in in june 2009 only about a month after you arrived yes yes let's look at the document
00:24:59 five two rbk3052528
00:25:06 now this is an email chain from june 2009
00:25:09 2009 i'd like to start with it with page three please with an email from janice ray
00:25:13 ray to you on the 17th of june 2009 which you could see halfway down well now fully on your screen uh and to liam good
00:25:21 liam good you may have been the liam you were i think reaching for before copy to lornette pemberton and adrian bowman and um he or rather she is advising you
00:25:32 and um he or rather she is advising you about an enforcement notice from the lfb you see that yeah and uh she uh says this is to advise you that the fire brigade informed us this morning that they intend to serve an enforcement
00:25:43 that they intend to serve an enforcement notice jointly on us and the council i'm not sure how exactly how this will be worded but it will relate to a lack of progress with fire risk assessments in the communal areas of our blocks as required by the
00:25:54 required by the regulatory reform fire safety order 2005. the background to this is as follow
00:26:00 follow uh and then you see paragraph two last year we were contacted by the local fire safety team who requested a copy of our fire risk assessment for gilray house we submitted this and then
00:26:11 house we submitted this and then received a letter advising us that conditions specified in and required by the regulatory reform fire safety order 2005 were being contravened the specific area of concern was noted
00:26:22 the specific area of concern was noted as fire risk assessment not suitable and sufficient procedures to be put in place in relation to occupants of the building with reduced mobility close quotes this opened up a protracted
00:26:33 close quotes this opened up a protracted discussion with brigade on a whole range of fire safety issues and i met with the fire safety officers in order to try to clarify their requirements and then she continues on on topic my first question is do you
00:26:45 on topic my first question is do you recall
00:26:46 recall this email i yes i must have got it sorry yes uh you may not recall it specifically but showing it to you now does it refresh your recollection yes do do you accept that looking at
00:26:59 yes do do you accept that looking at this document you had been alerted to the need through the fire risk assessment process to put in place
00:27:06 in place procedures relating to the occupants of tmo buildings who had reduced mobility
00:27:18 so this is a so again i started in 2009 if you think this goes back to 2006 the key thing is
00:27:27 thing is that the fire began challenging is about fire risk assessments i think that's one thing which i was just finding out when i joined
00:27:34 i joined uh the issue of gilroy's i think was a sheltered housing scheme as far as that maybe not uh i don't think it was
00:27:45 maybe not uh i don't think it was all right that i apologize
00:27:54 can you repeat the question sorry yes um on this document do you accept that you had been alerted to the need through the fire risk assessment process for the tma to have procedures in place
00:28:06 for the tma to have procedures in place relating to the occupants of tmo buildings who had mobility issues i think it's alerted us to there's an issue and i suppose how we deal with it
00:28:18 deal with it yes alerting you to that issue yes yes can we then look at page two and the response from claire wise
00:28:29 uh really i think the uh the bottom of page one for this um this is an email that claire wise sends to janice ray on the 18th of june uh
00:28:44 to janice ray on the 18th of june uh which makes its way up to you a little bit later
00:28:47 bit later in the email string the same day 18th of june 2009 i'll show you that but let's just look at this one now claire wise was an occupational therapist at rbkc
00:28:58 therapist at rbkc and if you look at the second paragraph of this email which starts at the foot of page one at the top of page two she says
00:29:09 at the top of page two she says in the first main paragraph having said that there may be duties under the disability discrimination act which states that disabled people are not to be treated any less favorably than a person without a disability that
00:29:20 than a person without a disability that would therefore mean that if an evacuation plan is in place that would not be suitable for a person with disabilities then an alternative provision for disabled people needs to be in place i would also argue that the council
00:29:31 i would also argue that the council should address this under duties in the disability equality scheme
00:29:37 and then she also cites from other um british standards and then in the last paragraph says this would appear to be an opportunity for collaborative working
00:29:48 opportunity for collaborative working with the fire brigade to develop a model that can be applied across the remaining tmo buildings i would like to stress that i'm not an expert in this field i would however have an interest in assisting with resolving this matter can i suggest that
00:29:59 resolving this matter can i suggest that we meet to discuss the progress so far and consider a plan of action now would you accept that ms wise's clear advice here
00:30:06 here is that an evacuation plan needed to be suitable
00:30:09 suitable for a person with disabilities that's her view yeah yes well did you disagree with that view
00:30:18 as as i say 2009 the position was stay put and uh wait to be rescued by the fire brigade she's raised this this issue around
00:30:30 this this issue around i think has been raised before about vulnerability and disabled and the question i still think is in within general need the the the position had had and still was for quite a long time
00:30:43 had and still was for quite a long time that basically you stay put in your home and be rescued by the fire began no no what you just told us is that your general generally held or permanently
00:30:54 general generally held or permanently held
00:30:55 held principal view namely that where stay put is in place for a building uh you don't have to worry about disabled residents i think that's where what so i know there's a few more emails there are we're going to look at them
00:31:06 there are we're going to look at them yeah i just wanted to just wanted to understand your answer does it matter mostly because i'm looking at the emails that go forward because i was reviewed so i've just been trying to remember 2009 in these conversations so i apologize well
00:31:17 apologize well all right well maybe i'll come back to my question i just asked when i've shown you a bit more of the documentation but let's not let let's not forget about it um let's go on then um factual question was the offer of
00:31:29 um factual question was the offer of collaborative working taken up i think we had i can't remember i mean there was obviously correspondence when we went through things and i brought janus ray into
00:31:41 so yes can you remember whether claire wise's offer of collaborative working was taken up i can't recall it and then let's look at the top of the chain
00:31:53 let's look at the top of the chain which does come to you uh same day 18th of june
00:31:57 of june 20 2009 at 1623
00:32:02 derek and robert two updates my h s manager alexis correa uh has spoken with building control who have today confirmed that the fire risk assessments are not robust enough and that a
00:32:14 are not robust enough and that a specialist should be engaged to carry out ras on all the relevant blocks at some cost
00:32:18 some cost the council will need to be satisfied that the specialist consultants carry out this work to a good enough standard alexis is in contact with janice ray and also he'll be drafting a note to fire service advising that we will take
00:32:29 fire service advising that we will take action to move forward quickly and progress what is required just pausing there and linking back with what you said earlier on in your evidence is that uh what triggered the instruction of salvas and the eventual production by them of
00:32:41 and the eventual production by them of their report yes yes and then he then she goes on secondly below you will see an email note on emergency egress for disabled people from flat and tall buildings the writer claire wise works
00:32:52 buildings the writer claire wise works for me
00:32:53 for me but is undertaking research for her m.a on this issue and is helping rewrite the british standard on dwellings as the bf doesn't mention provisions for disabled people now you accept i think that gene
00:33:05 now you accept i think that gene daintith
00:33:06 daintith first makes clear the need for specialist consultant on this subject doesn't she in terms of fire risk assessment yeah yeah indeed and and somebody who'll carry the work out to a good enough standard yes yes
00:33:18 out to a good enough standard yes yes uh and she says well rbkc has got internal resources namely claire wise do you agree that that would have been an excellent resource for the tmo to use essentially a free resource i
00:33:33 it depends because the first bits about the fire risk assessments and that was through saviles
00:33:44 sorry so i i can't remember i'm sure there's a conversation here where we go down which is probably coming up in terms where we get down to peeps which i believe
00:34:00 you think there was a conversation about using claire wise's services i can't remember at this moment and
00:34:12 we don't see any documentary evidence to show that the offer of collaborative working or use of claire wise by the tma was ever discussed further than this
00:34:23 discussed further than this or taken up i i can't remember if you haven't seen it it probably had didn't happen right do you know why that might be
00:34:32 i think this uh so again i have to just look at the date june so it's a month after i joined where i'm submerged in uh
00:34:44 where i'm submerged in uh quite substantial issues that i take owners
00:34:47 owners when i took honest their role as chief exact so i had a huge amount of issues to deal with my board as a tenant management organization and the membership because actually that
00:34:58 and the membership because actually that had fallen away i i was dealing with uh people who were leaving so i was having to recruit either
00:35:04 either temporary or long-term people so as chief exec i think my mind and focus wasn't here and i would have probably have asked janice to have a look at it to see
00:35:16 asked janice to have a look at it to see what we do do you remember whether you did well i think i did right because i think there's an email later where we talk about it let's look on then
00:35:24 then the next thing we need to look at is back to the sellers management report from the 22nd of september 2009 at sal 6013
00:35:31 6013 uh we've we've looked i think now probably twice at hazard 9.3 on page 11
00:35:39 and the criticism and the existing control measures i've read these two before i'm not going to read them again
00:35:49 but it goes on to say in the in the italics
00:35:52 italics italicized text on page 11. it does not appear that there is adequate liaison with fire and rescue services in regard to pre-planning for potential fire scenarios
00:36:00 scenarios or in agreeing appropriate fire safety standards for adoption by tmo from the findings of the fire risk assessments [Applause] uh and then uh if you look
00:36:14 uh and then uh if you look at uh page 18.
00:36:19 i'm sorry i'm i'm so sorry 9.3 stay on page 11.
00:36:24 page 11. uh it goes on to say against lack of inadequate lack of inadequate procedure for disabled and or vulnerable persons information as to the location of vulnerable persons appears to be collated by tmo
00:36:35 collated by tmo and then in italics it could not be confirmed if the information relating to the location of vulnerable persons is up to date there does not appear to be any formal procedures in place to deal effectively with fire safety issues associated with
00:36:47 with fire safety issues associated with disabled or vulnerable people you see that
00:36:50 that so that that's a criticism that's made if we go to the action required to reduce that risk it's a page 18 against 9.3 and if we look at that
00:37:04 against 9.3 and if we look at that it says it is strongly recommended that the tmo consider development of formal procedures to deal effectively with fire safety issues associated with disabled or vulnerable tenants and leaseholders and also any employees
00:37:16 and leaseholders and also any employees this should include a range of options from relocation etc etc and i've read that to you i think before as i say now it's clear that salva do you accept it it was clear from this that salvas's opinion was that the tma
00:37:27 that salvas's opinion was that the tma was in breach of the rro for that failure in their view what about your view you
00:37:38 in their view what about your view you didn't think it was in breach what i'm trying to remember is in terms of uh
00:37:44 of uh general needs in terms of actually managing 10 thousand homes with a range of people in it who's most the time you don't have infra much information is how you would
00:37:56 much information is how you would actually take this forward i think there's a huge debate in the sector
00:38:03 sector over these issues in terms of actually can you
00:38:07 can you create that infrastructure to do that when a lot of times you don't have the information i think that's probably where i was struggling with this in terms of actually how do you get the information well let's just take this in stages uh as you told us
00:38:20 in stages uh as you told us the lfb this is at the time of your arrival or before the lfe were not happy with the fire risk assessments being produced by the tmo yeah the result of which was the instruction of selvus
00:38:30 selvus yeah they came in they come in services opinion as we can see here is that the tmo were in breach of the rro in respect of at least in respect of the failure to
00:38:41 at least in respect of the failure to develop formal procedures to deal with fire safety issues affecting vulnerable residents that was their view you could see that yeah yes
00:38:50 yeah yes did you not think at the time that it was important to ensure that that
00:38:55 breach that they were identifying would be cured
00:39:00 be cured again i think there's a process i went through here in terms of actually how do we do this in terms of because again my experience in managing general needs
00:39:12 my experience in managing general needs is overall this wasn't done you collected information but actually you didn't have an active spreadsheet or computer program that showed the the position of every tenant
00:39:24 showed the the position of every tenant in general needs because you didn't know and how would you find that and it's almost in the sense of that the process is self-referral so again if someone referred this so in sense people would refer
00:39:35 so in sense people would refer themselves to us or we would have social services refer themselves to us or a housing officer might notice and we had substantial aids and adaptation budget which we then uh focus on so that once someone is
00:39:48 uh focus on so that once someone is identified as needing that they would have a visit probably if it's through social services an assessment of their property would be done and the teemo then we'd be giving a range of options for that tenant not for leaseholders i don't
00:40:00 tenant not for leaseholders i don't think to actually have adaptions made to their home to allow them to stay there if and i didn't see that very often if it was that they couldn't stay there
00:40:11 was that they couldn't stay there because of their health then you would have to look as i said there to resettle someone either to
00:40:16 either to a sheltered house and if that was more appropriate or registered care that was the sort of process that was in place about how the tmo would actually deal with people with
00:40:28 would actually deal with people with vulnerability and disability it wasn't
00:40:33 it wasn't i was supposed to say not a proactive position in terms of trying to find it
00:40:38 find it although we did collect information we tried to put it on the system so that actually if someone had issues that the contractors or the staff would know and be able to go there
00:40:50 you can see that under 9.3 the recommendation strong recommendation is to develop or consider development of formal procedures to deal effectively with fire safety issues
00:41:01 effectively with fire safety issues associated with disabled or vulnerable tenants and leaseholders so there is no there's a question there's a question did the tmo consider development
00:41:12 did the tmo consider development of such procedures well i think they consider the development of an aids and adaptation policy which we worked out with the council to try and support people in their homes
00:41:23 as long as they could
00:41:26 which was sort of standard in general needs property across the the sector we were quite lucky because we had more of a budget and aids adaptation aids adaptations than i'd had before
00:41:37 adaptations than i'd had before yes so it meant we could actually do it and those were recorded on the system so we knew about that and if people needed further help we'd refer them signpost them to our bkc because it may be some people need more
00:41:49 because it may be some people need more social services or social care support which we wouldn't be able to do yes i understand that an aids and adaptation policy to support residents in their homes who needed it is one thing
00:42:01 needed it is one thing but did that policy include formal procedures to deal with what would happen to those residents in the event of a fire either in their
00:42:12 in the event of a fire either in their flat or in the building i don't think so no no why not because i think again the general perception and general needs that
00:42:22 that if you're in general needs you you stay put or if you have a fire in your flat you should be able to get out and shut the door and contain the fire how would you get out if you were
00:42:33 how would you get out if you were disabled mr black why so it depends on your disability and what aids adaptations there are
00:42:42 well are you saying that where a person was disabled there was a policy in place to cater for what that person should do in the event of having to leave their flat if there
00:42:54 of having to leave their flat if there was a fire what i'm saying is they if we're
00:42:56 we're notified that a person was having difficulty living in their home
00:43:02 and we were referred those individuals either by themselves their family or social services we would then look at their flat with social services to see what we could do to maintain them in their home
00:43:14 their home maintaining someone in their home is one thing
00:43:17 thing developing a plan for assisting them to evacuate their home in the event of a fire in their home is another isn't it yeah i know what i said we probably didn't have that in place right thank you now um let's look at tma100318
00:43:32 thank you now um let's look at tma100318 so i'm sorry three one zero seven eight
00:43:37 uh this is uh the main tmo health and safety policy which we looked at before dated july 2010
00:43:46 2010 uh and we've seen that before that it bears your name and date yeah if we look at your responsibility on page two in the third paragraph
00:43:56 paragraph um executive or chief executive the chief executive is the person who is ultimately responsible for the tmos health and safety work activities and business he's responsible for the implementation
00:44:07 he's responsible for the implementation and review of all company arrangements for health and safety you see that yeah and the chief executive was obviously you at this time and they're after yes yes and and then below that under
00:44:18 yes yes and and then below that under executive team uh there are five bullet points there uh and you can see there um what they are for example
00:44:30 um what they are for example uh ensuring that a senior manager continues to chair the health and safety committee
00:44:37 committee do you accept that you were responsible for ensuring that the executive team did each of these five things yes yes and themselves as
00:44:48 and themselves as responsible individuals who worked within the company
00:44:53 what do you mean by that so it's my responsibility this is saying if you're doing this rule this is your responsibility as it cascades down health and safety while sitting with the chief exec it's ultimately this is
00:45:05 chief exec it's ultimately this is saying it sits with everybody in the sense of
00:45:08 sense of uh if you're out in a state and you see something blocking a passage where you should do something about it if you're say something that causes a danger you have to do something about it individually you don't call the chief exec and say
00:45:19 exec and say this is there so in a sense this is saying for my managers you need to take responsibility yes it's a pyramid isn't it you're at the top the executive team is next down and
00:45:30 top the executive team is next down and below that they have people answerable to them
00:45:33 to them that's how delegated management works all i'm suggesting to you is that at the top of the pyramid you were the top and the executive team was immediately below you yeah yes can we go to page six please third
00:45:44 can we go to page six please third paragraph under fire safety and emergency procedures because we're on the topic of disability and in the last paragraph in that section you see that it says this employees with disabilities have their
00:45:56 employees with disabilities have their own individual personal evacuation plan which is regularly reviewed and where necessary their colleagues are trained in the safe use of the evacuation chair now as you can see there's no mention there of any fire safety procedures
00:46:08 there of any fire safety procedures for disabled or vulnerable tenants or leaseholders is there no uh even though that had been advised as necessary by salvas in september 2009 i think they said yes i accept that i
00:46:21 i think they said yes i accept that i think when i look at this this is talking about as an employer not just a landlord which offices are slightly different from people's homes so you have different situations so my
00:46:32 so you have different situations so my responsibility to my staff and running an office i have to comply with that it might not be different but it's a different sort of situation where you have different resources different situations compared to general
00:46:43 different situations compared to general needs flat which people live in and they live there they're not
00:46:51 yes i mean this is not this document correctly i'm wrong but this document is not solely directed at employees it's also it also covers residents doesn't right yes so are you able to explain why
00:47:04 yes so are you able to explain why despite salvas's advice and recommendations in september 2009 there is no mention of any
00:47:11 any fire safety procedure for disabled or vulnerable tenants or leaseholders in this document because i think it's the same position i've said before that the chairman's policy was stay put stay
00:47:22 chairman's policy was stay put stay safe and be rescued by the fire brigade
00:47:29 even though in fact where you did have disabled residents and an aids and adaptation policy that policy didn't cater for what should happen in the event of a fire in that person's flat
00:47:41 event of a fire in that person's flat i think the policy in that flat in that particular flight sorry rather than outside yes where stay put wouldn't apply yeah well then there's strategies as get out and shut the door how does a
00:47:52 as get out and shut the door how does a disabled person do that again like i said it depends what their disability a person with a stick does that mean that you you would actually have to do some kind of review active proactive or or responsive to
00:48:05 active proactive or or responsive to make sure that where you knew about people with mobility difficulties or any other vulnerability uh you had to you had to make sure that at least you had some kind of plan so that they could evacuate their own flat in the event of a fire i think it
00:48:18 in the event of a fire i think it generally and its in the in the sector then
00:48:21 then within general needs it is still you stay put
00:48:26 stay put stay safe and be rescued
00:48:32 and i'm struggling with the logic mr black forgive me you can stay put and stay safe if there's a fire somewhere else in the block
00:48:41 the block yes you can't stay put and stay safe if there's a fire in your flat can you so again if we didn't know that person
00:48:49 person so if we didn't know that person had such a disability they couldn't get out we wouldn't know that well that's the problem isn't it yeah so unless someone so again i think the principle was still that if we are
00:49:01 the principle was still that if we are told
00:49:04 told and we can do things uh right so if someone i'm trying to think of an example we had a fire a property uh as a leasehold one where the person was not able to move
00:49:16 where the person was not able to move but she had a day that she had a carer sleeping carer in that case
00:49:21 that case even with the carer the the they had difficulty getting out and it's it's one of those things again i would say in that case it's a real challenge about whether that person should have been in general needs
00:49:32 should have been in general needs because there should be some exception that they can get themselves out well you may be are you making the point that the general elite housing should have no
00:49:41 have no vulnerable or disabled people in it at all
00:49:44 all there's a range of vulnerability and disability as well and what i'm saying is that overwhelmingly in the sector the position
00:49:52 position was stay pat stay put stay safe unless it's in a scheme which is designed to have that level of support
00:50:00 support to be able to support those individuals because again if it happens during the day that might be different because you might have the staffing ground if it has it happens in the evening there is no staff
00:50:10 staff there to actually implement the plan either way i think you accept that this document at the very least
00:50:17 least contains no indication of how the tma would manage fire risk in respect of disabled or vulnerable residents or relevant persons they're visitors for example
00:50:27 example yes yeah now can we look at uh another document
00:50:30 document uh this is the november 2013 fire safety strategy
00:50:34 strategy authored by ms ray tmo double zero eight three zero five nine eight we can see reference to peeps at page 24 on page 14.
00:50:46 [Applause] and under paragraph 24.1 it says staff who are not fully able-bodied and who made it need assistance to be alerted to the fire alarm etc
00:50:58 fire alarm etc are required to have a personal emergency evacuation plan peep and it goes on but again you can see that there's no mention there of any disabled or vulnerable resident is there
00:51:09 vulnerable resident is there no because i think this is specifically aimed at staff who are in my offices usually during nine to five when there's other staff about to be able to provide the support to vacate that
00:51:20 provide the support to vacate that person there wouldn't be been expense again the offices went open late in the evening
00:51:26 evening if a person like that had been in office with no other staff then you wouldn't have been able to to do that action so this is very much about a work environment which we also have responsibility for and not about actually
00:51:37 and not about actually in a home environment but you agree i think that this fire safety strategy uh covers uh residence doesn't it as we've seen already from section 1.1 on page one
00:51:48 page one apart from inside staff who are not able-bodied it doesn't say staff and residents who are not able-bodied no indeed it doesn't my point is that the fire safety strategy which ms ray authored in november 2013
00:52:01 which ms ray authored in november 2013 uh is directed both at staff and residents isn't it yeah and i think if it said staff and residents who are not freely able then that would be fair it says staff
00:52:12 that would be fair it says staff specifically the paragraph ex explains a work environment where staff are working in an office
00:52:18 an office yes i think we're agreeing with each other vigorously mr black you accept that there's no mention in this document of any policy or plan or procedure for dealing with disabled or vulnerable residents yes yes
00:52:30 residents yes yes and that was do you accept contrary to selves's advice in september 2009 yes it's advice and i think again advice within a sector where that is not normal uh policy and
00:52:43 where that is not normal uh policy and procedure
00:52:44 procedure to have that at that time well let me ask you
00:52:47 ask you again sorry so in sense of self-referral you know if people come forward a bit in the sense of that sorry i thought i'll finish
00:52:58 that sorry i thought i'll finish my mumble apologies yes we can talk about gathering data as a separate question i'm really just interested in why there's no policy and you say it's only advice and advice
00:53:09 and you say it's only advice and advice in a sector where that's not normal policy at the time
00:53:14 was there any conscious decision taken by the tmo not to carry into effect salvas's september 2009 advice about
00:53:25 salvas's september 2009 advice about having specific policies in place to deal with vulnerable residents i think looking at it it's we probably looked at it and then
00:53:37 we probably looked at it and then haven't developed that advice to take it into general needs
00:53:47 i'm sorry i'm not and forgive me i'm not sure i answer i understand your answer do you remember whether a positive decision was taken not to follow the salva's advice about it about vulnerable residents
00:54:01 i can't i can't remember i but i think we probably did right so yes so do we take it then on your evidence that the absence
00:54:13 on your evidence that the absence of any reference in this document to peeps for vulnerable residents was as a result of a conscious decision by the tma i think peeps comes up in another document
00:54:25 peeps comes up in another document in terms of health and safety and i think because we had sheltered housing we might have had some peeps there so i think depending on the environment the resident was living in our action
00:54:36 resident was living in our action would be different i just wonder whether i might get an answer to my my question um is it your evidence that the absence of any reference in this document
00:54:45 document to peeps personal emergency evacuation plans
00:54:49 plans was as a result of a conscious decision by the tmo i would say yes you would say yes thank you
00:54:57 now
00:55:01 we've also got the communications with the board on this subject which i'd like now to examine with you uh can we pick this up at tm0100-37442
00:55:14 this is part of the health and safety annual report for 2009 to 10. and page one shows that it is part of
00:55:29 and page one shows that it is part of page one is the agenda item two for the tmo board
00:55:33 tmo board on the 22nd of july 2010 if we go to page 38 we can see the health and safety annual report for
00:55:44 health and safety annual report for 2009-10 if we skip briefly to pages 52 to 53 very bottom of 52 over to 53 we can see at 52
00:55:54 at 52 it's it's uh janice ray who has signed it
00:55:58 it and that was the top of 53 just to finish that you can see that she has done so as tmo health and safety advisor now if we go back please to page 38 we can see the start of this report
00:56:13 this is july 2010 and it's at the same time as the health and safety policy we looked at earlier we can see at page
00:56:21 at page 38 the introduction and under section 2 the
00:56:26 the health and safety relationship between tmo and rbkc and if we move uh to page 50
00:56:36 we pick up the point about fire safety here
00:56:41 and if you look uh at the title ongoing health and safety risks faced by the tmo um 17.2.1
00:56:52 the tmo um 17.2.1 there are two bullet well there are three bullet points on that page let's look at the second one fire safety and it says this fire safety despite the measures outlined at seven above
00:57:02 above that we are taking to improve the fire safety of people and property this will continue to be an area of potential risk for the tmo it is essential that we continue to give priority to the communal fire risk
00:57:13 priority to the communal fire risk assessments and specifically to progressing the high priority recommendations as a matter of urgency
00:57:18 urgency additionally however it's important that we maintain a high level of inspections etc
00:57:22 etc to maintain our blocks as hazard free as possible that we review our smoke alarm policy to ensure that we maximize the installation of these units across the stock
00:57:31 stock and we continue to publicize fire procedures and identify residents with special needs and work with them to establish a specific personal emergency evacuation plan peep to ensure their
00:57:42 evacuation plan peep to ensure their safety is protected now the position there is being made clear to the board isn't it namely that the tmo is actively engaged in the process of
00:57:53 is actively engaged in the process of identifying residents with special needs for the purposes of providing them with a peep yes yes yes yes that does that not suggest or did that not suggest to the board
00:58:06 or did that not suggest to the board the conscientious board member perhaps reading this report that the tmo was active as opposed to reactive
00:58:14 reactive i think we're active in trying to collect information to give us a better picture of our residents
00:58:22 residents and if we came across someone who required
00:58:25 required this because i think it's still there if we came across someone that required a peep
00:58:29 peep if it's beyond what then we would do that
00:58:33 that but again we just have to look in the context of how you could carry it out right it says and identify residents it doesn't say uh
00:58:45 and identify residents it doesn't say uh to depend upon residents to identify themselves does it yeah i mean yeah but the route yeah okay yes i mean yeah but do you say the reality is as you described it earlier
00:58:57 reality is as you described it earlier yeah
00:59:00 at this point july 2010 are we to take it because of what janice ray is telling the board here that the decision not to develop
00:59:10 develop peeps for a vulnerable residence in the tmo stock had not yet been taken can you sorry can you repeat that are we to take it that at this point july 2010 because we
00:59:21 that at this point july 2010 because we see here
00:59:22 see here what john israel is telling the board about about the development of peaks for residents with special needs that the decision had not yet been taken not to develop a strategy or plan for
00:59:34 not to develop a strategy or plan for such residents reading that yes yes you say the decision
00:59:39 decision was taken was it but sometime between july 2010
00:59:42 july 2010 and november 2013 yes because i think yes like i think the context of this is at the time there was quite a lot of discussion in the sector around
00:59:53 the sector around uh how does general needs manage for vulnerable people when it's stopped because we've already heard about the the different legislation around us
01:00:01 around us i think the lga was doing a big piece of work
01:00:05 work uh around this uh which uh sort of went which we contributed not me but the policy groups within the sector and what came out really was uh that
01:00:18 and what came out really was uh that peeps really don't work in general needs so
01:00:22 so it in a sense and then that was adopted by most people across the sector and it listed all the reasons why because the lack of staffing nobody there during the evening trying
01:00:34 nobody there during the evening trying to make it it sort of worked during that context where
01:00:40 where you've got no staff on duty
01:00:44 um now we can continue on in the um story with this uh if we go please to an email chain from september 2010
01:00:57 rbk3026862
01:01:00 um the email i want to show you is on page two yes i've seen that thanks yes uh and uh this is from uh gene dantis
01:01:12 dantis uh to you brian and robert claire wise works for my business group the attached article was published in the journal of the fire protection association and outlines her research into provision within existing fire
01:01:23 into provision within existing fire safety and housing legislation to meet the needs of people living in flats in tall buildings the research was part of claire's msc in accessibility and design for which was rewarded a distinct awarded a distinction
01:01:34 awarded a distinction i thought you'd both find it interesting and might want to share it too i thought robert could perhaps respond to me regarding
01:01:39 regarding where we might learn from claire's findings
01:01:42 findings um it looks as as if gene dainty wanted an answer from you didn't she yes and i think i responded you did um and we can go up before you before we do do you
01:01:55 up before you before we do do you remember
01:01:56 remember looking at reading the article by claire wise
01:01:59 wise i yes probably yes yes rather than probably sorry you do just for our reference purposes is rbk303073
01:02:10 is rbk303073 did you think it was relevant particularly in light of salvas's recommendations and the inadequacy of the tmas procedures as picked up in its report i think i read it and i thought how does
01:02:22 i think i read it and i thought how does it fit within the context of general needs housing in london and how to make it work so you had your doubts yeah let's look at your response so yeah
01:02:36 we see your response on page one robert black to gene danith and brian deans 30th of september jean and brain but i think that's brian
01:02:49 jean and brain but i think that's brian thank you
01:02:50 thank you for sending me the attached article outlining the potential conflict for disabled
01:02:54 disabled people between fire safety and high-rise living
01:02:57 living i feel it's worth reiterating that as we have now completed the fire risk assessments on all of our potentially high risk
01:03:02 high risk which includes all of our high rise blocks and in each case the evacuation strategy
01:03:07 strategy has been confirmed as being staple at defending place specifically the assessments have confirmed that because these blocks consist of purpose-built self-contained dwellings
01:03:15 dwellings and the compartmentation is good if a fire were to break out elsewhere in the block the residents would be safe to stay put
01:03:21 stay put obviously if the fire was within their flat they should evacuate immediately however with regard to emergency procedures for disabled residents we are aiming to produce personal emergency evacuation plans peeps specifically as and when people's
01:03:33 peeps specifically as and when people's disabilities are brought to our attention
01:03:35 attention there is a need to produce a peep to clearly identify what their emergency procedures would be and if necessary to fit devices to help them help give them early warning of fire in truth to date we have only done this in
01:03:47 truth to date we have only done this in a small number of cases most notably where residents had no hearing and impaired speech and or were blind and we liaised with the lfb to fit the most appropriate detector however the fire risk assessments have clearly identified the need for us to
01:03:59 clearly identified the need for us to extend this work in relation to residents
01:04:01 residents known by us to have disabilities uh and i'll just finish it off um the fras themselves have sometimes identified individual residents
01:04:12 identified individual residents who we should target and the tp tracker and big
01:04:16 and big wow work will clearly identify others we were planning to work with the new fra consultant to produce generic peeps for larger blocks that could then be personalized to individuals needs i hope this is
01:04:27 to individuals needs i hope this is helpful in addressing the issues raised in the article robert
01:04:34 now what you say there basically is that high-rise blocks have a stay-put strategy
01:04:41 strategy yes yes but then if a fire is within a flat then the occupant should evacuate yes yes but your your aim i think is this right is that for disabled people vulnerable
01:04:52 is that for disabled people vulnerable people your aim is to introduce peeps i think at that time i've been new to the job
01:05:00 the job hearing i mean i mean again this was an aspirational aspect to me that would quite like to have done this or a responding positively to it i think what so that that's my yeah
01:05:11 i think what so that that's my yeah before a ramble on yes but you would only do that as and when disability people's disabilities were brought to your attention yes in other words reactively yeah yes uh and the peeps is this right
01:05:22 yeah yes uh and the peeps is this right would be
01:05:24 would be this was the idea individually tailored to advise them and assess any additional measures
01:05:28 measures i think in principle that's what you're trying to do yes um but the tma was recognizing the need i think to broaden this initiative through the fire risk assessments to extend peeps to all residents with
01:05:39 extend peeps to all residents with disabilities that was my aspirational yes he said it was an aspiration at that time so this is september 2010 uh
01:05:53 you uh refer there to the tp tracker as i've just shown you that last paragraph did you know what that was yeah it's tenant profile tracking we had
01:06:04 yeah it's tenant profile tracking we had a
01:06:04 a there's a company if i remember rightly gave us a trial period with it uh
01:06:12 but in sense it didn't the trouble we had is it had to sit on our system and i think over the time we use it it didn't really work uh i don't remember the details apology i can't remember what big one was
01:06:23 i can't remember what big one was i must accept was it used it by the tm there was a trial and then it didn't work so we stopped doing it right that was i think in 2008 wasn't it you remember that remember the
01:06:35 wasn't it you remember that remember the license
01:06:35 license for the tp tracker was not renewed in july 2013. i do know you've told me right but that does that ring a bell with you no yes i i see what was the big wow i don't know to be honest would you rate
01:06:47 i don't know to be honest would you rate it so i thought i know the trouble was right so i apologize
01:06:52 apologize trouble with writing anything i don't know i tried to look it up the other day but i didn't get anything no one seems to know what that was yeah i probably lost myself somewhere right
01:07:04 now what you say in your email here uh of 30th of september 2010 is not what is stated
01:07:11 stated in the tmo health and safety policy of july 2010 only a few months before which bore your name why is that sorry can you cut yes can you account for the fact that um your as you call it aspiration
01:07:24 um your as you call it aspiration to have peeps for all the residents in general needs housing was not reflected in the
01:07:28 in the general health and safety policy that you signed on in july twenty does i think this is an america i mean probably this is emerging thing that has been brought to my notice by the executive director at rbkc so in the sense having said this
01:07:42 so in the sense having said this i i was settling into my role and hoping maybe you could do this and it didn't happen
01:07:55 this email doesn't set out how people were to make themselves known to tmo in order to obtain a peep does it well i mean usually how people make themselves known to is as either phone is up
01:08:06 either phone is up send us an email and pop into one of our offices
01:08:09 offices because actually as a tmo we developed three offices eventually three offices but they were open during office hours or accommodating so they were based on estate so in terms of easy access
01:08:20 estate so in terms of easy access you didn't have to send an email so there was many ways that residents could let us know if they wanted or
01:08:27 wanted or had issues or concerns that we could address but it's it's ad hoc isn't it it's not really a strategy or policy or procedural protocol which would be a general application i suppose it the difficult gut
01:08:40 suppose it the difficult gut so this is a period where i'm trying and thinking we do something new what you'll probably show me later is that we didn't do it and and the reality we then adopted the alg guidance which basically says peeps
01:08:51 guidance which basically says peeps don't work until unless it's special uh situation and i think we're still struggling with peeps today i mean i don't i don't think it's seen as
01:09:02 i don't i don't think it's seen as it would be great to do there's current consultation with the home office on peeps i don't know if the panel know and i still know policy people in the in the business forgive me mr black i i
01:09:15 in the business forgive me mr black i i fear we're getting into i know but i think i was trying to just express to you the the issues of trying to actually take this forward becomes more and more difficult the more
01:09:26 becomes more and more difficult the more you're in general needs and i can recognize the whole issues about vulnerability and how people get out
01:09:31 out but there is just evidence and evidence evidence that in general it doesn't work for all of general needs there may be specific cases
01:09:39 cases and a point i was trying to link which might not be relevant but i just think from a personal point of view having going through this is the government is still struggling to move it from a reactive service to a
01:09:50 move it from a reactive service to a proactive service so it's not just the tmo so i know people might say it should be proactive but reality they've changed their position from proactive to reactive again
01:10:00 again because pressure from the industry the private sector the social housing and local authority because they struggle with how you can do this with the resources they have and i don't even mean errors but in
01:10:12 and i don't even mean errors but in terms even private companies how do they do it
01:10:15 do it leasehold does you know all the private companies
01:10:19 companies they've all fought back at the government that is really difficult to do
01:10:23 do and actually changes the whole nature probably of general needs housing that's the only reason i wanted to to link it in because obviously i struggled with it at this time
01:10:33 time and and the sector still struggling with it now have you seen any peeps at that stage late september you know but i'd seen them before in my previous row when i managed the support and care
01:10:44 row when i managed the support and care company with the circle 33 in circle anglia
01:10:47 anglia because we had them specifically there for the customer base that we had do you know whether any had in fact been carried out by the tma as at the end of september 2010 what i
01:10:58 as at the end of september 2010 what i was only
01:10:59 was only in terms of the ones i was told was janice because she would know where they were so
01:11:03 were so in terms of i took her guidance on that
01:11:09 now let's look on at what the board was told in the next health and safety annual report for the following year 2010 to 2011 tmo double zero eight five four eight
01:11:20 tmo double zero eight five four eight nine
01:11:20 nine zero page fifteen item two fire safety
01:11:31 [Music] and
01:11:36 under under item 2 fire safety this is part of the objectives for that year you can see in the third line it says it is essential that we get continue to
01:11:47 it is essential that we get continue to give priority to the commonal fire risk assessments that we complete the lay risk fra program in the next reporting period and continue to progress the high priority recommendations as a matter of urgency
01:11:58 urgency specifically we aim to progress the flat entrance door replacement within available budgets and to seek further resources should these be necessary and then towards the bottom of the
01:12:09 and then towards the bottom of the paragraph you say we could continue to publicize fire procedures on the website in the residence handbook articles in the link etc and identify residents with special needs and work with them to establish
01:12:21 needs and work with them to establish a specific personal emergency evacuation plan peep
01:12:24 plan peep where necessary to ensure their safety is protected so that was part of the report that year to the board
01:12:33 so it looks as if nothing changed the following year did it it was still as you might call it an aspiration it's not an objective and i don't think we gave up that if if we find someone
01:12:44 we find someone that required it if the kings is we do there wasn't a general no go away i think individually we would have to look at each individual to see what we could do and actually my
01:12:55 to see what we could do and actually my team
01:12:56 team if they find people in the circumstances would actually look at a range of means for them it may be again as i said that we would refer them to rbkc in terms of their their sort of
01:13:08 to rbkc in terms of their their sort of social need or it may be in the end that we would actually encourage them if we had a place to move to somewhere where more appropriate for their needs i think it was still there because we still might find people
01:13:20 still might find people uh who had it or came to us but then you'd have to look at how you do it if you go to the bottom of page 14 you can see that what i've just read to you was part of this report which which
01:13:32 was part of this report which which covered health and safety objectives for 11 12. so i i ask again just with that in mind it's right isn't it
01:13:42 it that the production of specific peeps for those residents who were identified and leave aside how they were identified uh remained part of the projected policy
01:13:54 uh remained part of the projected policy for that year 11 12. yes then if we look at the corresponding report for the next year 2012 to 13. that's a tmo double zero eight seven nine
01:14:05 eight seven nine seven four seven uh and mr chairman perhaps i'll just cover this one off before the break um if we can look at that please and look at page 18
01:14:20 item 18 health and sale health and safety objectives so 12 13. you see that and if you uh look at subparagraph two
01:14:31 and if you uh look at subparagraph two towards the foot of your screen fire safety
01:14:34 safety that's the topic there and if you go to the following page page 19 towards the end of that paragraph you'll see it says about 10 lines up from the bottom finally you see finally it's important that we
01:14:46 you see finally it's important that we continue to provide residents with fire safety information stroke advice stroke guidance
01:14:50 guidance publicized fire procedures on the website in the residence handbook articles in the link etc and identify residents with special needs and when necessary work with them to draft a specific personal emergency
01:15:01 to draft a specific personal emergency evacuation plan peep to ensure their safety is protected uh so again it looks as if for that year projected projected to 2012 to 13.
01:15:16 projected projected to 2012 to 13. so again within our stock we we had sheltered housing we had we managed the scheme that was a higher care managed by another i think was octavia
01:15:29 managed by another i think was octavia we had a a support service for people that hash triusman ran so we had to have it there because if those people required it it's there yeah and again i'd say if a general need
01:15:42 yeah and again i'd say if a general need outside those services if a general needs person came and said that or their family said there was issues we would look at on an individual base when i first read this because i hadn't seen this for ages
01:15:54 seen this for ages i think it was fine to be there because aspirationally we would still as a company try everything's possible to
01:16:01 to support people but we didn't have a policy of
01:16:05 policy of of going out because we just weren't able to do that well well do you accept that this you call it an aspiration but this plan we've now seen in three successive health and safety
01:16:17 three successive health and safety annual reports and i think it's sorry which project to the next year the proposal to have those residents who are identified with special needs
01:16:29 with special needs to be given a specific personal emergency evacuation plan yes yes and if you look also at the end of this paragraph it says additionally it's proposed that
01:16:40 it says additionally it's proposed that this area of work will be subject to an audit
01:16:42 audit in the coming business year
01:16:47 do you know why that sentence was added i had i not not at this moment no do we take it from the decision to add that to this report to the board that
01:16:59 that to this report to the board that not only
01:17:00 not only was there going to be for the following year
01:17:04 year uh the uh the policy pursued of drafting specific peaks for specific residency residents but that that
01:17:15 residents but that that process would be subject to an audit i have
01:17:18 have i can read it but i'm afraid i can't remember specifically why that would be added
01:17:24 uh mr chairman there's there are two or three more i think in this line but i'm happy to take the break now yes well i think probably mr black and indeed all of us would benefit from a short break
01:17:35 benefit from a short break mr black we'll have a break now we'll come back please at 25 to 4 and again i must ask you not to talk forever to anyone about your evidence while they're out of the room absolutely thank you
01:17:55 right 25 to 4 please
01:36:52 would you ask mr black to come back in please thank you
01:37:13 thank you good thank you yes now um can we then look please at the the uh next report for the next year
01:37:32 tmo10031069 uh and this is the uh annual health and safety annual report for 2014 to 15 and if we go to page 13 so we've now passed
01:37:46 13 so we've now passed the time when the 2013 november 2013 fire safety strategy had been drafted you see
01:37:53 you see and if we look at section 14 health and safety objectives for 1516 underneath that you'll see paragraph 14.2
01:38:03 14.2 a substantial amount of is undertaken to ensure fire safety such as and then if you um go over the page
01:38:17 and then if you um go over the page to page 14 you will see after the bullet points uh there's discussion of continued liaison with the lfb
01:38:28 with the lfb and then four lines five lines up from the end you say well it says additionally it's important that we continue to provide residents with fire safety information stroke advice direct guidance publicize fire procedures on the website
01:38:40 publicize fire procedures on the website in the residence handbook articles in the link etc and identify residents with special needs and when necessary work with them to draft a specific personal emergency evacuation plan peep to ensure their safety is protected you
01:38:52 to ensure their safety is protected you see that
01:38:53 see that yes and the date of this report as i can just show you that is page 17 june 2015.
01:39:05 now there's no substantive change in the wording is there as between the report we saw for earlier years in relation to peeps and this report
01:39:13 report no although there's a reference although the reference to having the audit has gone
01:39:19 gone uh do you know why that was no um at all events by this stage we're now as i say past
01:39:25 past the november 2013 fire safety strategy but these reports to the board are still telling the board uh that your team is still where
01:39:37 uh that your team is still where necessary working with residents with special needs to provide them with peeps why was that because i think it's what i said before we mostly general needs but we did have a range of housing that supported other
01:39:49 a range of housing that supported other individuals therefore actually if in sheltered heist and someone required the pay you would do it if you took it out
01:39:55 out so it is you know we had a supported house inside and those people might actually then find needs which they might need to pay that so it's there as a thing to ensure we're covering all their customer base
01:40:07 we're covering all their customer base or resident base this doesn't draw the distinction between general leeds housing and sheltered housing does it i accept it
01:40:17 it looks as if no from this document that no decision in fact had been taken by the tma's executive team as you told us earlier not to do peeps for residents in general
01:40:28 not to do peeps for residents in general housing
01:40:30 housing i'm not sure if i agree with that because we also adopted the lga guidance which i think is in one of these as as well saying that actually as ld guidance came out what's the position with general needs
01:40:44 well if you were let's just break this down
01:40:47 down do you remember when the lga gardens came out mr black was it 2011 i can't remember off the top but it was it was
01:40:58 it was 2011 july 2011. uh do you remember sitting down with janice rayne looking at it in relation to peeps
01:41:07 to peeps not relation to peeps no i probably sat down and talked about the general thing in general needs
01:41:15 you told us earlier that a specific decision had been made by the tmo not to do peeps for residents in general housing
01:41:23 housing was that decision taken after the lga guidance had come out is that what is that how you recall it that's how i i can't recall i'm not going to speculate sorry i apologize if any such decision whether or not
01:41:36 if any such decision whether or not based on the lga guide from july 2011 had been taken can you explain why
01:41:41 why year after year after year right up to this report in june 2015 looking ahead to the next year 2016 the board is being told
01:41:52 year 2016 the board is being told that your team is identifying residents with special needs am i necessarily working with them to develop peeps and again if we identified people who required that we would do it i don't think that's the point if
01:42:04 i don't think that's the point if someone comes along and says they require repeat we would have to look to it or we may have looked at other options so what decision did you take on the basis of the lga guidance then
01:42:15 the majority is that actually peeps are unsuitable for general needs
01:42:22 for all the sorry i don't i can't remember the wording in the how they say it
01:42:30 what decision what decision what did what did the tmo decide to do vis-a-vis peeps after the lga guidance had come out do you say right
01:42:45 afraid i can't give you a clarifying answer for that i would say the reason it's probably still here is as i said if we identified someone that required it and we could do it we would they'd be
01:42:56 it and we could do it we would they'd be self-referral in line with the guidance it sounds to me as though what may have happened
01:43:04 happened is that instead of there being any formal
01:43:07 formal and certainly any documented decision it was allowed to drop on the basis that it was thought not to be appropriate right we probably accept that
01:43:17 well let's
01:43:22 jump ahead to the last annual health and safety annual report from 2016 to 17 at tmo double zero eight eight zero five five zero
01:43:40 and this is as you can see the 2016 to 17 report
01:43:45 17 report and if we go to page 18 item 14 2 again we can see
01:43:54 again in the last part of the last paragraph
01:43:57 paragraph the words additionally where vulnerable residents with special needs are identified we aim to work with them to clarify their specific emergency procedures and ensure their safety is protected now the word or expression peeps doesn't
01:44:08 now the word or expression peeps doesn't appear there so somebody has clearly applied their mind to the language of that sentence can you confirm it sorry a bit blind where we are there sorry i'm so sorry we are at the foot of page 18.
01:44:20 so sorry we are at the foot of page 18. at the end of the section entitled fire safety just above contract and management the last sentence there additionally where vulnerable residents with special needs are identified we aim to work with them to clarify their
01:44:31 to work with them to clarify their specific emergency procedures and ensure their safety is protected that that's that's different language isn't it from the previous years yes which referred to peeps the reference to peeps has dropped but
01:44:42 reference to peeps has dropped but clarifying specific emergency procedures it has been put in that but that would indicate wouldn't it that somebody has actually
01:44:48 actually applied their mind it's not a cut and paste somebody's actually thought about what to say here i think it's a review and probably there was that's where barbara looked at it with her team
01:44:59 where barbara looked at it with her team and
01:45:00 and and changed it so i have to accept that yes
01:45:04 yes at all events there was still a plan leaving aside how you identify the residents there was still a plan to work with them to provide them with peeps wasn't there
01:45:16 peeps wasn't there well that's not what it says now as you've pointed out well uh you said yes i'd understood your answer essentially to be saying the same thing but yes
01:45:27 thing but yes yes and again could we take it then that really up until the time of the fire the tmo's policy at least looking at what the board was being told is that peeps were being produced
01:45:40 is that peeps were being produced with those residents whose special needs were identified for the purpose it said we would produce seeps if we didn't give a list of peeps we had in the
01:45:50 the organization of how we done sorry i i are you by that answer telling
01:46:02 sorry i i are you by that answer telling us that
01:46:03 us that this was still only an aspiration looking forward but you hadn't yet produced any peeps i can't tell you off the top about how many peeps were produced i'm looking at this in a den fund as you said it's
01:46:16 at this in a den fund as you said it's trained so thank you
01:46:22 let me cut through this do you accept that the board is being told that as at the date of this report and looking forward to 2017-18 the tma's policy was
01:46:34 to 2017-18 the tma's policy was at that time to produce peeps for those with special needs identified yes if identi if identified right
01:46:46 if identified right and how did that tie in with the decision
01:46:50 decision not to produce peeps as a result of reading the lga guide some years before
01:47:00 i've been tied up in knots yeah sorry
01:47:05 i think the key thing is we work with them to see what's best if there was a requirement or a need you'd have to do it in this individual basis i think that's what this is trying to say
01:47:15 to say and i'm struggling a bit right now going on to the question of identification there's no clarification here or indeed in any of the earlier reports to the
01:47:27 in any of the earlier reports to the board about how it would be that residents would be identified is there no no or of how many people had so far been given peeps or in the language of this last report
01:47:38 in the language of this last report specific emergency procedures yes yes how could you monitor the effectiveness of this this aspect of fire safety management without that information
01:47:52 it'd be difficult um is it right to say that you personally were assuming that the tmo was in some form or other collecting or collating the necessary information and then acting on it where
01:48:03 information and then acting on it where necessary
01:48:07 uh we're collecting information and i found information that was relevant this yes
01:48:12 yes did you yourself even check to verify that assumption no no why is that because i would imagine
01:48:19 imagine that i have a management team managing that and they have they would be monitoring it speaking to the staff
01:48:29 did you ever ask to see a peep no do you know how many were actually no i said no
01:48:37 i didn't really because i take your point they weren't recorded no we've i think identified two in the many years between of carl stokes's
01:48:47 stokes's tenure as far-risk assessor uh would you accept as a matter of common sense and this may be wrong but i doubt it that there were rather more than two vulnerable people in the borough in your housing you were
01:48:59 in the borough in your housing you were vulnerable it's hard enough to accept that and in the end do you accept that the ultimate effect
01:49:07 effect of your failure to the tmo's failure to set out any substantive policy or strategy in respect of disabled or vulnerable residents or a clear policy of collection
01:49:18 policy of collection of data about those those individuals
01:49:23 was that the tmo was unable to identify all of the relevant vulnerable people in grenfell tower on the night of the fire i think we we're probably clear we
01:49:34 i think we we're probably clear we haven't wouldn't have been able to identify all the people who lived in the ten thousand properties
01:49:41 because again it wasn't a proactive position
01:49:44 position we were in to do that and it was still to stay put and be rescued let's look at a document tmo double zero eight six six zero zero two
01:49:58 this is a list of grenfell tower residents produced by david noble of the tmo on the night of the 14th or morning of the 14th of june 2017
01:50:09 2017 early in the morning while the fire was raging there are on this document on our count 10 residents of grenfell tower who are identified with vulnerability and you can't see the vulnerabilities
01:50:21 and you can't see the vulnerabilities because it's they've been redacted let's be honest with you unless you're very lucky you can't see anything much on this document no you can't uh it's a document that mr noble gave evidence about and that's why
01:50:33 noble gave evidence about and that's why i'm slightly uh taking this slightly quickly i don't know whether uh blowing this up is going to help at all uh my my i'm putting to you let me put to
01:50:44 my my i'm putting to you let me put to your proposition and see if you agree with it
01:50:46 with it that none of the individuals are on the the noble list which which is this document had a people prepared for them none of the people identified on this
01:50:57 the people identified on this list as having vulnerabilities had a peep prepared for them i think that's probably true yes can you explain why that is i because i said did they present
01:51:08 i because i said did they present themselves to the table was the information shared
01:51:13 what system was put in place to ensure as best you reasonably could that all residents were aware that they ought to tell the tmo
01:51:25 that they ought to tell the tmo of their vulnerabilities by the whether of a mobility uh or any other kind so as to enable the tmo to prepare a peep for them
01:51:38 i don't think we had that in place why is that
01:51:41 is that because i think again the policy or the situation was if you if you're having to live in your home and you tell us then we would be able to do something about it
01:51:55 let's turn to a different topic
01:51:59 which is oversight of fras fire risk assessments now in general terms mr black would you agree with this proposition that it was it was part of the role of senior management or the executive team at the
01:52:11 management or the executive team at the tmo
01:52:12 tmo to monitor the effectiveness of the arrangements made to comply with the fire safety order the rro and with the fire
01:52:19 the fire risk assessment process yes yes and periodically to review those arrangements yes yes yes let's then look into a bit more detail at the chain of command for health and
01:52:30 at the chain of command for health and safety and specifically fire safety um is it right that at the bottom of the chain of command you have uh cyril morris and adrian bowman who were line managed by janice ray yes yes and until
01:52:42 janice ray yes yes and until july 2015 janice ray reported to anthony parks and after july 2015 to barbara matthews yes yes uh and bubba matthews was part of the
01:52:54 uh and bubba matthews was part of the et the executive team yeah we've explained before that janice ray was not part of the executive team it's right that she wasn't part of the senior management team at all wasn't she i can't remember
01:53:08 i can't remember i think we i think knew i think we discussed that earlier today right is it right that there was no senior manager who uh as it were represented her or her information
01:53:21 represented her or her information at senior management team meetings other than anthony parks before july 2015 and barbara matthews thereafter at senior manager team meetings yes
01:53:35 yes i said yes oh you said yes i'm sorry i didn't tell you i didn't read the transcript now janice ray's role description from 2012
01:53:44 2012 uh uh well let's look at the document um it's
01:53:49 tmo10031076 please
01:53:57 uh this is a statement of intent with your name at the bottom dated december 2012. uh and if you uh look at uh pay i'm sorry statement of
01:54:08 uh look at uh pay i'm sorry statement of intent health and safety policy december 2012.
01:54:11 2012. and if you go to page three of that health and safety policy document of that date paragraph 2.7 uh you can see the health and safety facilities manager
01:54:20 manager in bold is responsible for and the health and safety facilities manager was
01:54:27 was janice ray at all times wasn't it yes and we could see a number of bullet points
01:54:31 points setting out her responsibilities and the second
01:54:35 second of those uh is the formulation of all health and safety policy and strategy yes yes and producing all health and safety policy procedures and guidelines and ensuring that these are regularly
01:54:46 and ensuring that these are regularly reviewed and kept up to date now do you agree that she had a very significant and senior role in determining the health and safety policies of the tma yes yes and there was nobody in fact
01:55:00 yes yes and there was nobody in fact this is a matter of impression i suppose but do you agree that there was nobody at the tma who had more knowledge about health and safety who could question or challenge what janice ray determined
01:55:11 janice ray determined was appropriate policy other than herself
01:55:16 sorry can you say it again well let me try a different way was there anybody who knew more and had greater experience of health and safety uh
01:55:24 safety uh than janice ray i agree yes and therefore there was nobody within the tmo who was appropriately equipped by experience or expertise to challenge or question what janice ray
01:55:36 to challenge or question what janice ray decided
01:55:37 decided should be appropriate health and safety policy and strategy i agree yes and would that include uh operating the fire risk assessment
01:55:48 uh operating the fire risk assessment program
01:55:49 program yes yes and indeed i think it's the case that janice ray created the november 2013
01:55:55 2013 fire safety strategy yes and the 2017 version of that same strategy yes yes and indeed janice ray who was recorded as being
01:56:06 as being the responsible person perhaps it means the competent person for grenfell tower in the lf epa inspection forms yes yes
01:56:17 in the lf epa inspection forms yes yes now do you agree with me that the fire risk assessment program was the chief means by which the tmo could satisfy itself that it was
01:56:28 could satisfy itself that it was complying with the rro yes can we look at pas 7 again please we looked at part of this before
01:56:40 and go please to page uh one this is um bsi 6071
01:56:48 bsi 6071 uh page one just to put the first page of the document in front of you it's not i think a document uh that you were familiar with as you told us but let's go to page 23
01:56:59 told us but let's go to page 23 paragraph 7.4.1
01:57:06 fire risk assessment 7.4.1 the organization should establish implement and maintain a formal documented risk assessment program that systematically identifies fire hazards
01:57:17 systematically identifies fire hazards and persons especially at risk analyzes fire prevention and fire protection measures
01:57:21 measures evaluates fire risk and formulates a suitable action plan and then there's a note this fire risk assessment process can be performed in accordance with past 79
01:57:32 accordance with past 79 which includes a pro forma or any other risk assessment methodology that suits requirements and prohibitions imposed on top management by fire legislation and then 7.4.2 the organization's fire
01:57:44 and then 7.4.2 the organization's fire risk assessment program shall include a a defined scope including its limitations b a procedure for the assessment of competency of the fire risk assessors c strategy for risk assessment risk
01:57:56 c strategy for risk assessment risk treatment risk acceptance and risk communication 7.4.3 the organization shall audit the fire risk assessment program after the delivery of the risk assessments 7.4.4
01:58:07 assessments 7.4.4 the organization shall conduct a review meeting at planned intervals to discuss the results of fire risk assessment audits and efforts to address findings were you a remind me of this because i
01:58:21 were you a remind me of this because i think you gave evidence on this earlier were you personally aware of this guidance at any time in terms of how to do fire risk assessments in terms of leo i i wasn't i'm not familiar with the
01:58:32 i i wasn't i'm not familiar with the paper
01:58:34 paper did you take any steps to ensure that the principles in this guidance that i've read out to you were followed i i would have thought that
01:58:45 i i would have thought that they work with the company that did the high risk
01:58:48 high risk strategies would have created a framework in line with this document because they were the specialist company is that salvos yeah i see so
01:58:59 is that salvos yeah i see so so far as salvas's work in 2009 and early 10
01:59:03 early 10 is concerned on high risk buildings including high rise buildings in your stock you say that this was observed you know what i'm saying is since that
01:59:14 you know what i'm saying is since that company specialized in this i imagine they would observe this because that's their key business so it's just me speculating yes it's probably the same thing of course
01:59:25 it's probably the same thing of course salvas was operating in the high risk um part of your stock in 2009
01:59:29 in 2009 and 10 and this document was published in 2013.
01:59:34 in 2013. but you say that salvas observed it um what about the tmo because if this is all about the organization isn't it establishing and implementing and maintaining a formal documented risk
01:59:46 and maintaining a formal documented risk assessment program
01:59:50 my question is did you take any steps to ensure that the tmo established such a program no why not again
02:00:03 no why not again my understanding is the fras were compliant with the area and they were seen alongside the specialist risk
02:00:14 seen alongside the specialist risk management we employed and therefore it would be acceptable
02:00:23 what do you mean by seen alongside the specialist risk management we employed i think the point you were making earlier is that actually within the tmo the jana said no equal in terms of knowledge of health and safety
02:00:34 knowledge of health and safety for the role she played they're very absolutely the fire risk assessor would be a person she'd be able to check things with make sure that actually it's in line with legislation
02:00:46 with legislation that would be my thinking right do you remember whether a positive decision was taken by the tmo not to establish implement and maintain a formal documented risk assessment program
02:00:57 program in the way that's identified here with all the features set out in i don't think they would have made a decision not to do it it just didn't happen yes
02:01:08 didn't happen yes right so is it your evidence that whatever janice ray and carl stokes did from 2010
02:01:19 ray and carl stokes did from 2010 onwards
02:01:20 onwards that either did or didn't satisfy these provisions all these this guidance there's nothing beyond that i said my assumption is that it would because that was their
02:01:29 was their their role can you just help me with this the
02:01:32 this the the way that paragraph 74 is worded uh suggests that the organization ought to have some sort of override overarching um plan as to what it was
02:01:46 overarching um plan as to what it was going to do in relation to fire risk assessment within which the actual fire risk assessments themselves would form part
02:01:59 can you help us about what the tmo did in relation to any form of overall plan as to what they were going to do about fire risk assessments in general
02:02:12 fire risk assessments in general which then led to the appointment of
02:02:16 service we go right back to salvos i mean well was there some sort of any sort of consideration of an overall um plan which might be regarded as
02:02:29 um plan which might be regarded as a fire risk assessment program
02:02:34 which within which the individual fire risk assessments and in this case the appointment of salvas sat as part of the implementation of that program do you think you understand what i mean
02:02:45 do you think you understand what i mean yeah i think i suppose i'm trying to say is i wasn't in place for uh 2008 2006 nine when they were doing all this stuff that all the salvage stuff all
02:02:57 that all the salvage stuff all started round about when i came it sounds of how to address the the criticism of the system that had been in place uh for a number of years so a point in them
02:03:08 them dealt with the issue that fire brigade was dealing with in terms of their how they viewed it it also gave us the you know the framework to complete these fras within the three year period which i think we agreed
02:03:19 agreed and and splitting the stock into the high medium and low and the impression i'd get well of course if there were any attempt to formulate an overall plan it would have predated your appointments well one thing
02:03:31 appointments well one thing [Music]
02:03:33 [Music] but it maybe there wasn't any attempt to stand back and consider an overall scheme and the fire risk assessments um simply carried on in a different form
02:03:48 just following up on on chairman's questions
02:03:52 questions just looking at uh 7.4.1 and 7.4.2 here on the screen in front of you we've seen no formal documented risk program
02:04:02 program that does those things required by those paragraphs have you i know no we've not seen any evidence of any audit under paragraph 7.4.3
02:04:13 7.4.3 have you
02:04:19 no i can't recall nor any documents showing that there were review meetings under paragraph 7.4.4 have you
02:04:29 and that it meaning sense of looking at that one
02:04:35 i mean they were reviewed at the health and safety committee
02:04:39 to look at the findings
02:04:45 so you say the health and safety committee meeting minutes looked at the results of fire risk assessment audits
02:04:55 as opposed to the fire risk assessments
02:05:04 themselves [Music]
02:05:19 can we look in this connection at uh tmo double zero eight eight three five six eight
02:05:37 and this is uh a meeting of the tma board
02:05:41 board this is the minute and in fact this is the
02:05:45 the the program in fact for the meeting on the 26th of july 2012 uh this is i think the first page of a board pack of some 123 pages and if we go please to page 41
02:05:57 go please to page 41 we will see the tma's performance agreement for 2012 2013 and it this is uh appendix 2 as you can see from the top left-hand corner
02:06:08 left-hand corner to the tma performance update at page earlier on and if you go to page 42 please in that you can see uh under hr
02:06:20 please in that you can see uh under hr and organizational development can you see is it under audit 3.4 the draft audit program for the next year is set up below other audits hr and organizational
02:06:31 other audits hr and organizational development and then two underneath that fire risk assessments lawnette pemberton full review
02:06:37 review it looks from this is this right that the tmo's intention at that stage was to carry out a full audit into fras in 2012 to 13. it looks like it yes yeah
02:06:49 in 2012 to 13. it looks like it yes yeah did we don't see any evidence that that order ever took place did it take place or um are you right that it didn't i'm not sure i mean it would if it took place you should be able to find results
02:07:00 place you should be able to find results from our auditors yes we haven't been able to do that that would rather suggest that it didn't take place
02:07:05 place are you able to explain why it didn't take place no now uh we know because you've helpfully
02:07:16 now uh we know because you've helpfully told us
02:07:17 told us that salvas was instructed as a result of concerns raised by the lfb in the summer of 2009 the tmo was producing in-house fras that were inadequate
02:07:28 inadequate the the the result of that is that salvus entered into a contract to conduct fras for all of the tmo's high-risk properties didn't it yes yes and we know from carl stokes
02:07:40 yes yes and we know from carl stokes he's evidence that he was employed or or potentially contracted in by by salvas to produce the fire risk assessments for some of those buildings including grenfell tower yes
02:07:51 grenfell tower yes yes and we've seen that now can we look at an email that you received on the 4th of july 2009
02:08:00 rbk3053546 let's go to the foot of page 1 in that email run
02:08:09 email run it's an email from judith blakeman to you 4th july 2009 and also to laura johnson dear mr black and miss johnson in light of the tragic fire yesterday in camberwell
02:08:20 camberwell i would be grateful if we can have risk assessment and report on the means of escape
02:08:24 escape in the event of fire covering all the tower blocks in the tmo's ownership within the borough at grenfell tower for example because of the council offices and emb offices on the lower floors getting out of this building by the
02:08:35 getting out of this building by the stairs is extremely difficult and one can end up at a dead end i would like to invite you to a company company me up to the top floor to see how difficult it would be to get out of this block
02:08:46 it would be to get out of this block in the event of an emergency i look forward to an early response now given what counselor blakeman says there can we take it that you were aware of fire risk assessments as a concept
02:08:58 assessments as a concept uh in or by july 2009 yes yes uh and also that councillor blatant had specific fire safety concerns about grenfell tower itself from the summer of 2009 specifically in
02:09:11 from the summer of 2009 specifically in relation to the means of escape right yes now let's look at laura johnson's
02:09:16 johnson's response higher up page one if we can please
02:09:19 please she says uh and it's dated the 5th of july 2009
02:09:22 july 2009 and you're copied in fact you're an addressee
02:09:26 addressee councillor blakeman the royal borough is at present in discussion with the tmo on commissioning consultants to undertake a review of the relevant fire risk assessments of the communal areas of the council blocks as this is legally required by the
02:09:38 as this is legally required by the regulatory reform fire safety order this process to date has been managed by the tma but it has been brought to our attention by the fire brigade that this will need to be more rigorous therefore officers from the tmo and our
02:09:49 therefore officers from the tmo and our bkc
02:09:49 bkc are in the process of setting up a working party to look at various things and you can see the bullet points set out there comply with the arrangement proposed arrangements review challenge and support the consultant's
02:10:00 challenge and support the consultant's recommendations review considerable cost implications agree how they'll be funded i hope this answers your question uh in the short term and when we have more information as a result of the review work we will
02:10:11 as a result of the review work we will be able to brief counselors more fully can we take it then that you were aware at this time as a result of seeing this email on the 5th of july 2009 that the the tmo needed to conduct more
02:10:24 the the tmo needed to conduct more rigorous fras in order to meet its regulatory requirements i mean i think this follows from the letter we got from the fire brigade then in june and this follows on yes
02:10:37 so being a new person who's just started the month before and walked into this yes it would seem that i'm being told and therefore i'm agreeing with it because i say before i have no history
02:10:48 because i say before i have no history of what they were doing before in the second bullet point you could see at the end of that sentence that it refers to sign off with the fire brigade what did you understand laura johnson to mean by that
02:10:59 i i mean i think what i don't know what i might imagine she's mean is actually once we agreed that the process of a uh the f iric a's right i think so did you respond to
02:11:12 a's right i think so did you respond to councillor blakeman's invitation to uh can to go on a site visit
02:11:18 visit at grenfell tower to look at the means of escape i can't remember i've been trying to find an email
02:11:24 an email from anything when i was doing preparation for this in terms of it would be very unusual if i didn't because actually usually i when i've just started you've got accounts were asking you so i can't understand why i can't see
02:11:36 so i can't understand why i can't see any proof that i did i've i've been a previous grandfather old and new numerous times um was there a fuller briefing as contemplated
02:11:47 briefing as contemplated do you think
02:11:55 a fully briefing from laura to councillor blackman yes i can't recall you can't recall uh can we go to
02:12:05 three rbk3018531 please
02:12:12 this is an email uh from angus sangster at the lfb of the 10th of july 20 2009 to janice ray
02:12:21 ray and you can see that it's copied to you you're one of the last copies in the list of copy e's subject fire risk assessments for tma properties dear janice thank you for your email i
02:12:32 dear janice thank you for your email i must emphasize that time is against you bearing in mind the discussions regarding the provision of adequate fire safety measures in tmo building stock have been taking place with members of my team for over a year now can i
02:12:43 my team for over a year now can i suggest we have a meeting with mr robert black and gene danith sometime over the next week to discuss the type of undertaking that the lfe would accept well i accept that you've started on this work i'm still not happy
02:12:54 this work i'm still not happy that what's been supplied is sufficient to justify my team not undertaking enforcement action kind of suggests monday 13th july and or friday 17th july do you remember that
02:13:05 or friday 17th july do you remember that email
02:13:05 email uh you're not not previously no no do you remember whether there was a meeting
02:13:12 meeting as suggested i imagine if it's been sent to uh
02:13:19 i i can't remember we i i would imagine we would have done but i can't recall personally do you accept that right from the start of your time at the tmo
02:13:28 tmo bearing in mind you started work going in the may of this same year 2009 fire safety and adequate fire safety measures
02:13:36 measures were on your radar with you
02:13:41 yeah they were my radar since joining in may in june right and
02:13:47 right and grenfell in particular in light of concerns arising from the latino house fire
02:13:55 i'm not quite just specific to grenfell sorry well because of the email from judith blakeman oh that goes i apologize uh
02:14:08 what's the question again sorry that you were that also on your radar was grenfell tower particularly in light of concerns expressed by judith blakeman arising out of the fire at lack of house
02:14:20 arising out of the fire at lack of house in on the 3rd of july 2009 i think this i would have been concerned about everything as i was finding out not just specific about grandfather
02:14:34 can we go to tma100-37323
02:14:43 this is a briefing note
02:14:56 tmo10037323
02:15:07 uh it's entitled executive team fire safety update 29th july 2009 introduction the purpose of this briefing note is to update you with the current position on
02:15:18 update you with the current position on communal area fire risks assessments fras
02:15:21 fras and complying with the regulatory reform fire safety order 2005 rro and advise on what information is currently available on the cause of the recent serious residential fire that lacking house and how this relates
02:15:33 that lacking house and how this relates to our stock uh and it goes on to give a history of the issues as raised
02:15:43 raised by the nfb and they're concerned about the sufficiency of the fras carried out by the tmo at the time i'm summarizing very briefly what's in this document uh were you aware at that time that the
02:15:54 uh were you aware at that time that the tmo was conducting fras in-house
02:15:59 when i joined so i so know when no one mentioned ever race when i joined i went through a process when i came in in may and then july that is when i began to understand that
02:16:10 began to understand that that's what we'd be doing and then this challenge from the fire brigade that they went up to task right did you see this briefing note at the time uh i must have yes uh
02:16:21 uh i must have yes uh if you go to paragraph 5.4
02:16:30 the very bottom of the of the page there uh it identifies the completion of the consultant's brief completed by 17th july
02:16:42 completed by 17th july and sent out to four consultants uh uh
02:16:49 uh uh did you see that you think
02:16:53 i think i've said i've seen this could you see the consultant's brief i i can't recall let's go to page four heading six lakingal house you can see
02:17:04 heading six lakingal house you can see there there's a there's a a lengthy description of what happened in that fire and particularly a description of the block itself and it says the serious fire at this block is still under investigation and it's
02:17:15 still under investigation and it's likely to be several months before the causes are totally clear however we have received some information in relation to the layout of the block and factors which may have contributed to the seriousness of this fire
02:17:25 fire and we're investigating if any of our blocks have these features specifically first bullet block built around a single central staircase whilst we have many blocks which have
02:17:36 whilst we have many blocks which have only a single staircase we have no high rise blocks constructed around a central enclosed staircase grenfell tower has an enclosed single staircase but this block has additional fire safety features which were not
02:17:47 fire safety features which were not present in lagnal house automatic detection in the common parts which is linked to a mechanical extraction both of which are maintained regularly as part of a planned preventative maintenance contract and would serve to
02:17:58 maintenance contract and would serve to give
02:17:59 give give very early warning of fire and also extract smoke keeping lobbies free for safe evacuation do you know where grenfell tower was mentioned in this document as a consequence of councillor
02:18:11 document as a consequence of councillor blakeman's email of the fourth of july we looked at earlier no i i wouldn't i would think just say janice if it's
02:18:18 if it's from janus that she would identify that herself do you remember whether would you remember being conscious at the time that grenfell tower was a single staircase construction tower i would have only known through reading
02:18:29 i would have only known through reading this i wouldn't have known personally construction did the fact that it was mentioned specifically in this briefing note at the time and councillor blatant had highlighted a similar issue with the staircase caused you any
02:18:40 staircase caused you any concern at the time i i can't recall
02:18:47 now if you go to rbk three zeroes five
02:19:01 you could see that there was a meeting on the 6th of august 2009 at 3 o'clock in the afternoon attended by uh a number of people uh from uh rbkc from the lfb and keith holloway from tma
02:19:14 from the lfb and keith holloway from tma properties you weren't uh they're at least not listed as being there can you remember why you weren't there i not off the top prepared not on that day specifically early
02:19:25 specifically early early august possibly on holiday would you otherwise have been there i think so yes right now we can see that in attendance with gene danith the executive director
02:19:36 executive director and laura johnson housing department uh both from our bkc um were they as far as you understood it the two people responsible at rbkc for
02:19:47 the two people responsible at rbkc for oversight of the tmo yes and by extension oversight of the tma's management of fire safety yes do you remember being briefed on the outcome of this meeting
02:19:58 outcome of this meeting i i can't recall afraid right 11 years if you go to page four under paragraph ten you can see
02:20:08 uh there general discussion time scales for completion of risk assessments works completion uh in the last few paragraphs there you can see
02:20:18 can see uh that there's discussion of tmo appointing an external fra consultant isn't there if you look at the last um uh
02:20:30 um uh part uh yes keith holloway reiterated that the tma would complete their procurement program by september 2009 the risk assessments would be completed over the following 12 months
02:20:41 over the following 12 months yes yes were you briefed on on that fact after this meeting probably but again keith was a interim uh because actually everybody had left so
02:20:52 because actually everybody had left so keith was taking on a major role for me and attending these things while i was engaged in other aspects of the business so we probably did discuss it it records that angus sangster lfb replied he feels tmo need
02:21:04 replied he feels tmo need to develop the level of competence amongst their staff was that view communicated back to you after this meeting i don't recall that right he also suggested a member of staff from the
02:21:15 suggested a member of staff from the council tmo could be seconded uh into the lfb in order to gain experience of fire safety procedures do you remember being told about that proposal
02:21:24 proposal again i can't remember i might have been but
02:21:29 mr chairman it's a little early but maybe a convenient moment for a break we're into the topic but there's a long way to go and it's as good a moment as any to poor is it's also unconscious been a long day
02:21:40 it's also unconscious been a long day for the witness yes well mr jack i think it wouldn't hurt to finish it slightly early today so we'll call a halt there i'm going to have to ask you to come back tomorrow i'm afraid at 10 o'clock to answer some more
02:21:53 at 10 o'clock to answer some more questions
02:21:54 questions and in the meantime please remember not to talk to anyone about your evidence or anything relating to it okay all right and uh all right so we'll see you tomorrow morning if you'd like to give the usher now that'll be
02:22:05 to give the usher now that'll be fine thank you very much 10 o'clock tomorrow
02:22:16 thank you very much 10 o'clock tomorrow then thank you mr
02:22:30 you