Evidence from Barbara Matthews, TMO Executive Director of Financial Services with responsibility for health and safety oversight. Her testimony exposes systemic failures in fire risk management systems, lack of formal policies, and over-reliance on technical experts without independent verification.
00:00:27 yes we're sticking here no the next witness
00:00:29 witness might call barbara matthews thank you
00:00:44 might call barbara matthews thank you afternoon mr matthews uh you're going to make the affirmation i believe yes right well then would you please read the words on the screen in front of you yes i do solemnly sincerely and truly declare
00:00:55 declare and affirm that the evidence i shall give shall be the truth the whole truth and nothing but the truth good thank you very much sit down please make yourself comfortable
00:01:06 thank you um you've got a bottle of water have you got a glass yes oh good now i couldn't see it that's all right
00:01:13 all right thank you when you're ready there mr clay assistant would you please confirm your name for the record barbara matthews good afternoon afternoon miss matthews thank you very much for attending today um before we start uh in earnest on your
00:01:25 um before we start uh in earnest on your evidence there are three points which i should uh put you first of all if any time you require a break please say so that's not a problem secondly if at any time any of my questions is unclear please
00:01:36 any of my questions is unclear please say so and i'll rephrase them so that they become clear yes and thirdly and finally would you please keep your voice up during the course of your evidence that's so the shorthand writer can capture everything you say
00:01:47 capture everything you say inaccurately of course now ms matthews um you've provided two statements for this inquiry the first dated the 22nd of august 2019 which can be found at tmo1004987
00:02:01 which can be found at tmo1004987 is that it it is yes and your second statement is dated the 8th of december 2020
00:02:07 2020 which can be found at tm00873380 and is that it yes it is have you read both of those statements recently i have and are their contents true
00:02:19 i have and are their contents true they are true and are you content to have those statements stand as your evidence to this inquiry i am thank you now the first topic i'd like to
00:02:28 like to ask you questions about is your background qualifications and experience is it right that you are employed by the tmo as executive director of financial services
00:02:37 services and ict from june 2015 onwards it is correct and when did you stop being employed by the tmo i stopped being employed by the tmo when
00:02:48 i stopped being employed by the tmo when the tmo transferred its services to the council
00:02:52 council in february 2018 and then i was employed by the council rbkc did you at the time of your appointment have any formal health and safety management qualifications
00:03:04 safety management qualifications no did you have any form of health and safety treat training had you received any previously none but the normal sort of office health and safety training that
00:03:16 you often get in in a new role when you were appointed as executive director at the tmo first of all were you aware of fires in the united kingdom evolving cladding on high-rise
00:03:27 evolving cladding on high-rise residential buildings at the time i joined no i wasn't uh were you aware of the lachnal house fire in 2000 i was yes and in broad terms what did you know about it
00:03:39 did you know about it um my understanding there the issue was to do with compartmentation and the design of the building um and that um one of the reasons for the
00:03:50 that um one of the reasons for the deaths
00:03:51 deaths of of people was they were trapped in a room that they thought was safe and it and it wasn't so you were unaware of the role of cladding in that fire uh i was aware when you talk about cladding
00:04:04 i was aware when you talk about cladding i was aware that some of the under windows there are cladding panels
00:04:12 panels which may have had an impact on the fire but
00:04:16 but i cladding as a whole i was not aware of and were you aware of the recommendations that have been made by the coroner following the lachnal house inquest
00:04:25 inquest uh in relation to um compartmentation and um the the panels that you would that i mentioned they've got a name but i can't remember what
00:04:37 got a name but i can't remember what they're called i was aware of the recommendation with regards to design on buildings thank you now in paragraph seven of your first
00:04:48 seven of your first witness statement we don't need to go to it but the reference is tmo one double zero
00:04:52 zero four double nine eight seven forward slash two and the third sentence you say this
00:04:57 this one of my key functions was to monitor the tmo's health and safety performance from a strategic level that is it was my role to ensure that the tmo had a health and safety strategy
00:05:08 the tmo had a health and safety strategy in place there was up-to-date that identified programs of work training now before you joined the tmo had you held any previous responsibility for health and safety in any previous
00:05:19 for health and safety in any previous role
00:05:19 role no did you have any training or experience in the management of health and safety at this point no had you ever been responsible for the health and safety of housing stock such
00:05:30 health and safety of housing stock such as that managed by the tmo i.e 10 000 homes some council tenanted leasehold
00:05:35 leasehold sheltered housing etc what experience did you have before joining the tmo of fire safety management in the context of social housing um i hadn't actually managed fire safety
00:05:49 um i hadn't actually managed fire safety but obviously through the number of years that i've been in housing i'm aware of the requirements uh in in terms of fire risk assessments
00:06:00 in terms of fire risk assessments the actions arising from those and and sort of issues around uh compartmentation in buildings so i was aware of these things but i
00:06:11 so i was aware of these things but i didn't actually manage them myself now you may have been aware of them had you received any specific fire safety training in your previous roles no had you received any
00:06:23 no had you received any particular training on fire risk systems or fire risk management systems no did you have any training on fire safety in the context of asset management or housing stock whilst employed by the
00:06:35 or housing stock whilst employed by the tmo
00:06:36 tmo no did you have any training whether at the tmo or previously on the requirements of the regulatory reform fire safety order 2005 no were you aware of any of the
00:06:49 no were you aware of any of the supporting guidance first of all hamashi's government fire safety risk assessment sleeping accommodation which been published by the department for communities and local government um i am likely to have been
00:07:02 um i am likely to have been aware of it in previous executive roles but i can't specifically say that i that i had been through the whole
00:07:13 that i that i had been through the whole document
00:07:15 document was it then was it a document that you had cause to refer to during your time at the tma
00:07:21 not me specifically i would have expected janice my health and safety manager to review that document and bring any uh things to my attention she was the
00:07:34 things to my attention she was the expert
00:07:35 expert no we'll come on to ms ray in due course but looking at what you yourself did yeah um were you aware of the lay core's guidance on fire safety provisions for certain types of existing housing
00:07:47 existing housing published in 2008 i'm not sure that i was the local government association's publication fire safety and purpose built blocks of flats published in 2011.
00:07:58 flats published in 2011. i was aware of that document were you aware of this substance i i had read that document and had you read it before you joined
00:08:09 and had you read it before you joined the tmo
00:08:10 the tmo not before no and what prompted you to read it whilst you're employed by by the tmo uh i think janice would have brought it to my attention when we were having various discussions
00:08:22 when we were having various discussions about things i i can't actually remember if you can't remember then yeah i can't remember don't try and remember no um were you aware of the requirements of the responsible person
00:08:33 responsible person under the fire safety order um i was at the tmo through the work i did with janice but not before not before
00:08:44 were you given any specific training on the requirement of and the role of fire risk assessment
00:08:52 no now you go on to say in paragraph eight of your statement this and again maybe easier to have it up on the screen tmo one double zero
00:09:03 tmo one double zero four double nine eight seven forward slash two
00:09:06 slash two you say this my role in relation to health and safety at the tmo was managerial rather than technical it was my responsibility to ensure that janice ray had the proper support and resources to be able to carry out
00:09:17 and resources to be able to carry out her role
00:09:19 her role i provided this support to janus through formal one-to-one meetings every month during which we discussed issues service plans and anything else that was topical or an issue we would also identify what health and safety matters we felt needed
00:09:31 health and safety matters we felt needed to be included in the fortnightly executive team meetings and the annual health and safety report presented to the executive team and the board we also caught up weekly on a more informal basis
00:09:43 informal basis now you say in relation to health and safety your role in relation to health and safety was managerial rather than technical
00:09:48 technical did you have any technical experience for the role um no
00:09:54 um no not really i mean as it says there i i did not
00:09:58 did not i was not um the technical side that that was janus i was more managerial looking at the strategic role now would
00:10:09 looking at the strategic role now would it be fair to say that your responsibility um was broad in that it encompassed ensuring the health and safety of all tmo residents employees and contractors etc yes
00:10:20 employees and contractors etc yes now given your lack of technical ability did you rely entirely on janus ray to to determine whether tmo was acting as it should in relation to its health and safety obligations um i obviously
00:10:31 obligations um i obviously relied on on janus but also in terms of fire safety um that i relied on carl stokes as well
00:10:41 did you understand that the property portfolio over which you had executive health and safety responsibility was of a substantial size encompassing some 2 650 blocks yes i was
00:10:55 did you understand that oversight of health and safety for the tmo required a substantial level of leadership and organizational control yes now janice ray was not part of the senior management team at the tmo is
00:11:06 senior management team at the tmo is that right that's correct um she wasn't required to attend senior management team meetings for example again is that correct that's correct but in fact given that you were her line manager she was effectively at a senior
00:11:18 she was effectively at a senior management level is that is that a fair characterization that is a fair assessment of her role and certainly from the practical point of view yes now you state in paragraph eight of your
00:11:30 now you state in paragraph eight of your witness statement the one we just looked at
00:11:32 at that you and janet ray would identify the matters that needed to be included in executive team meetings and the annual health and safety report how did you determine what needed to be reported to the
00:11:43 what needed to be reported to the executive team um well a number of things would come up at the health and safety committee and janice and i followed up on various issues and some
00:11:56 followed up on various issues and some things would come to my attention through different means sometimes it was a matter of what was coming up in the sector um various sort of
00:12:08 various sort of general publications that came through email so we might decide there's a matter in there that ought to come to the executive team because it might be applicable to the tmo and its stock what
00:12:20 applicable to the tmo and its stock what type of issues who first of all who would determine what health and safety issues
00:12:23 issues were to be referred to the board
00:12:28 what was referred to the board would have been
00:12:33 have been the things that were shown in the annual health and safety report and also exceptional items for instance after the
00:12:41 after the fire today there were various reports that went to the board on that and the resulting enforcement notices
00:12:49 notices were there any instances where janice ray recommended that a health and safety issue should be referred to the board but you disagreed with her no were there any issues that you thought should be referred to the board and janet ray
00:13:00 referred to the board and janet ray asked you not to i don't think she ever asked me not to report something to the board or at least encouraged you not to put it before no she never did that now staying in this witness
00:13:13 did that now staying in this witness statement of paragraph nine you say this and i quote the tmo had a health and safety committee that met regularly while i chaired these meetings i made it clear to all those in attendance
00:13:24 clear to all those in attendance that janice was the manager and the expert
00:13:27 expert my attendance at these meetings was to highlight the importance of the tmo put on health and safety sasha jevons also attended as many matters concerning health and safety fell into her directorate was the
00:13:39 fell into her directorate was the practical result of your lack of technical knowledge that you deferred to janus ray as the expert on all aspects of health and safety including fire safety uh as i said yes yes but with fire
00:13:52 uh as i said yes yes but with fire safety
00:13:53 safety it was also carl stokes is it fair to say that your role as chair was essentially procedural i.e to run the meeting um i it wasn't just to run the meeting
00:14:07 um i it wasn't just to run the meeting because as you can see from my statements that one of the things that i do i did was to stress and challenge um and require
00:14:19 um and require people in the organization to do certain things so it wasn't just to sit there and chair the meeting so your contention would be it was a substantive as opposed to a mere
00:14:30 substantive as opposed to a mere presentational rule yes
00:14:33 can you help us what health and safety matters fell into sasha jevin's directorate um that they would have been the actions resulting from any of the health and
00:14:44 resulting from any of the health and safety
00:14:46 safety action plans in relation to maybe contract management or maybe planned maintenance even key documentation required that
00:14:58 even key documentation required that would come from the key keystone system so those were the sorts of things that fell into her area thank you ms matthews now i want to move now on to a new topic which is oversight of fire safety
00:15:11 is oversight of fire safety now can we look um first of all at the tmo's regulatory responsibilities in relation to fire safety first of all were you aware of the substance of the regulatory reform fire safety order
00:15:22 safety order um i probably was aware of some of it but maybe not all the detail
00:15:30 detail put differently had you sat down and read the order i hadn't read it front back no had you ever read any aspects of the order
00:15:37 the order uh i i believe i did in relation to uh fire risk assessments the need for fire risk assessments and what they needed to cover and what had prompted uh that
00:15:49 and what had prompted uh that investigation um probably my own uh knowledge to build up my knowledge because
00:15:55 because i was responsible for health and safety i needed to read things to ensure i understood certain things and fire risk assessments was one of the things that i was quite concerned about
00:16:07 things that i was quite concerned about and was that concern did that emerge at the start of your tenure as executive director or did it come later once issues regarding fras for example start to be discussed by the executive team uh now it came fairly early on when
00:16:19 team uh now it came fairly early on when i realized that there were a huge amount of
00:16:22 of actions outstanding from fire risk assessments were you aware of the concept
00:16:26 concept and the substance of the duties imposed upon the responsible person under the order
00:16:31 order uh i'm not sure that i was to be honest again looking at differently did you consider the tmo to be the responsible person in relation to grenfell tower
00:16:42 relation to grenfell tower oh no i believe that there were two you could say two responsible people because the actual building
00:16:53 because the actual building uh is owned by the council and we're the manager tmo was the managing agent so i felt that effectively there were two responsible people
00:17:05 two responsible people now can we look at uh some of the substantive requirements of the fire safety order and for that purpose could i ask you to go to inq
00:17:13 go to inq treble zero double one three two seven forward slash eight
00:17:21 now this is part two of the fire safety order and if i could ask you to look at article eight under the heading duty to take general fire precautions and it provides as follows the responsible person must that takes such
00:17:34 responsible person must that takes such general fire precautions as as will ensure
00:17:36 ensure so far as is reasonably practicable the safety of any of his employees and b in relation to relevant persons who are not his employees take such general fire precautions as may reasonably be required in the
00:17:48 may reasonably be required in the circumstances of the case to ensure that the premises are safe first of all were you aware of that duty i was yes were you aware of the tmos arrangements to discharge
00:18:00 arrangements to discharge that duty uh i was aware of
00:18:06 some of the the things in particular as i've mentioned fire risk assessments and some of the
00:18:19 checks that were going on in some of the buildings in relation to various i think you refer to them as fire systems so we can see that risk assessment is a
00:18:31 so we can see that risk assessment is a separate duty under article 9 just below can you give the panel an idea of the gist of the understanding of the checks that you were thinking of when you were
00:18:42 that you were thinking of when you were looking at article eight uh i you know i suppose i was thinking of
00:18:48 of the sort of inspections that occur of equipment
00:18:52 equipment in various buildings um how had you satisfied yourself that the arrangements for performing this duty imposed under article eight were adequate
00:19:03 article eight were adequate uh again i would rely on um uh the uh information i was getting about um health and safety um as i said fire risk
00:19:17 health and safety um as i said fire risk assessments and um the uh various audits that we even um genesis team undertook um various audits so i
00:19:29 um various audits so i would get my reassurance from from that did you exercise any independent review of your own to satisfy yourself regarding the adequacy of the arrangements
00:19:40 arrangements no i didn't
00:19:43 please say if this is unfair or not but would it be fair to say that if janice ray didn't give you any cause for concern you assumed that the arrangements for
00:19:54 you assumed that the arrangements for discharging the article 8 duty were in fact adequate
00:19:59 um
00:20:04 i'm not i'm not sure whether i would have assumed that um
00:20:14 can you just ask the question again just to make sure i've got the is it fair to say that if janice ray didn't raise any specific concerns you assumed or proceeded on the basis
00:20:25 you assumed or proceeded on the basis that
00:20:26 that the arrangements for discharging the obligation under article 8 were adequate um i it would not only be janice i would be relying on carl stokes um
00:20:40 be relying on carl stokes um and the audits that we also undertook internally so it wouldn't just be janus there'll be other sources upon which you yes now it's up on the screen we can see
00:20:52 yes now it's up on the screen we can see that article 9 risk assessment and we can see that article 9 1 imposes an obligation on the responsible person to make
00:21:00 to make a suitable and sufficient assessment of the risks to which relevant persons are exposed
00:21:05 exposed for the purpose of identifying the general fire precautions he needs to take to comply with the requirements and prohibitions imposed on him by or under this order would you agree that that duty required the responsible person to carry out a
00:21:17 the responsible person to carry out a suitable and sufficient assessment of risks
00:21:19 risks yes and in that regard did the rbkc do anything in relation to carrying out risk assessments
00:21:30 carrying out risk assessments your knowledge i don't know
00:21:35 did you proceed on the understanding that it was the tmo that carried out the risk assessments as the responsible person
00:21:42 uh well i must have done because i didn't know what rbkc were doing so i would as part of the tmo and being part of the responsible person
00:21:54 responsible person need to make sure that we had suitable risk assessment could i ask you to turn to article 9 via safety arrangements sorry article 11 i should say sorry
00:22:10 you see article 11 1 requires a responsible person to give effect such arrangements as are appropriate having regard to the size of his undertaking and the nature of its activities for the effective planning organization
00:22:22 for the effective planning organization control monitoring and review of the preventive and protective measures
00:22:28 measures eleven two goes on to impose a separate duty on the responsible person to record the arrangements referred to above where he employs five or more employees a license under enactment is enforced in
00:22:39 a license under enactment is enforced in relation to the premises when alterations notice is in force now would you agree with me that the tmos the responsible person is required to put in place an arrangement
00:22:50 required to put in place an arrangement to manage the risk of fire yes and that arrangement should set out in writing how the tmo would plan organize control monitor and review preventive and protective fire safety measures
00:23:02 protective fire safety measures yes who in the tmo was responsible for making those arrangements
00:23:16 well i suppose that was within my health and safety team and that would have been janice who would put
00:23:25 would put together the the documentation but some of the activity there would not necessarily be in her area
00:23:38 would not necessarily be in her area so he would be primarily responsible for ensuring that those arrangements were in place
00:23:49 because reading reading this as it's written um it uh it looks like there are responsibilities
00:24:04 there are responsibilities that are not within uh the health and safety area um but to
00:24:11 um but to ensure that certain things are in place that would be under health and safety and therefore janice reporting into myself and for which you had executive responsibility i did yes
00:24:23 responsibility i did yes now were the arrangements to discharge the article 11 duty were they set out in one or more documents
00:24:31 documents they were set out in the health and safety
00:24:34 safety policy and also in the fire strategy document as far as i remember the details of it now how did you satisfy yourself about
00:24:45 now how did you satisfy yourself about the adequacy of the the arrangement set out in those documents
00:24:49 documents those documents were reviewed during my time and we would have looked at the current legislation uh and regulation to ensure that they were
00:25:02 and regulation to ensure that they were up to date but also we would look at the um processes that we had in place now you've used the word we there the health
00:25:13 you've used the word we there the health and safety policy and the fire safety strategy
00:25:16 strategy they were reviewed by whom first of all janice would have done the first review but she would have sat down with me to discuss
00:25:23 discuss any proposed changes that we wanted to put in
00:25:28 put in did you propose your own changes or did you await
00:25:31 you await janice's proposals for changes um i we would have done the document sort of in in tandem where she would have gone through and put proposed changes in
00:25:43 proposed changes in i would have put what i felt needed to go in
00:25:46 go in there was an area on responsibilities that needed to be clearly outlined so and amended to to strengthen actually the role that i
00:25:58 to strengthen actually the role that i took
00:25:58 took within health and safety and that was your yes
00:26:02 your yes yes and in what respects did you consider that your responsibilities needed to be set out more succinctly or clearly because i think it was a bit woolly in terms of my role
00:26:13 in terms of my role in terms of health and safety and i think you
00:26:17 think you mentioned it when you said was my role just to
00:26:20 just to chair the meeting the way it was originally worded it looked a bit like that whereas in fact my role was to manage health and safety across the organization and it needed to
00:26:31 organization and it needed to put in that managerial responsibility thank you
00:26:35 thank you now can we look at some of the guidance that was available in relation to fire risk assessment and management systems i should say and first of all could i look at have you heard of if i refer to paz do you know what i'm referring to
00:26:47 know what i'm referring to uh publicly available specification seven
00:26:51 seven the only reason i know of that document is because i've seen the evidence come up i had not seen that document and you've never seen it before i hadn't until it came up in the evidence well
00:27:02 until it came up in the evidence well let us
00:27:02 let us go through that because notwithstanding the guidance there are some broad issues of principle that i'd like to discuss with you
00:27:08 with you now if we could look at pause 7 in its 2013
00:27:12 2013 version it's entitled fire risk management system specification can be found at bsi quadruple zero double
00:27:19 double zero seven one forward slash twenty
00:27:28 and if we could look in particular sub paragraph six point two point two one
00:27:36 which says the organizational shall employ
00:27:39 employ or contract with people who are competent on the basis of education training skills and experience for the tasks assigned to them and if we go further down that page to
00:27:50 and if we go further down that page to paragraph 6.3
00:27:56 under the heading awareness it says this person's doing work under the organization's control she'll be aware of a the fire safety policy b their contribution to the effectiveness of the
00:28:07 contribution to the effectiveness of the frms
00:28:09 frms such as the fire risk management system including the benefits of improved fire safety performance c the implications of not conforming with the fr and s requirements d any risk them arising from or in
00:28:21 d any risk them arising from or in connection with the work they're intended to do now would you agree that the guidance requires
00:28:26 requires competence for fire safety tasks assigned to relevant individuals yes and those within the organization including yourself
00:28:35 yourself should be aware of the tmos fire safety policy would you agree yes and you should be aware of your role in relation to the fire risk management system and policy would you agree yes and the implications of not conforming
00:28:48 and the implications of not conforming with the frms and the policy should be known to those assigned with fire safety responsibilities yes and one of those consequences of course is injury or death yes can we turn onto page 25 within this
00:29:00 can we turn onto page 25 within this document to section 8.
00:29:04 it's entitled management review and 8.3.1
00:29:09 8.3.1 apologies for reading this miss matthew is probably easier top management shall review the organization's frms at planned intervals to ensure its continuing suitability adequacy and effectiveness
00:29:21 adequacy and effectiveness note one review should include assessing opportunities for improvement and the need for changes to the management system including the policy and objectives note 2 they refer to a pro forma
00:29:32 note 2 they refer to a pro forma 83.2 the management review shall include consideration of a the status of actions from previous management reviews b changes in external and internal issues that are relevant to the frms
00:29:44 issues that are relevant to the frms see information on the fire safety performance including trends in one non-conformities and corrective actions two monitoring and measurement results three audit results
00:29:55 audit results four interested party feedback five evaluation of compliance or legal another requirements and then d opportunities and recommendations for continual improvement and then looking further to 8.3.3 the
00:30:07 and then looking further to 8.3.3 the outputs of the management review should include decisions related to a continual improvement opportunities b improvement related to interested party requirements c resource needs to enable improvement to
00:30:19 resource needs to enable improvement to the frms as processes and d any need for changes to the frms note the need for changes the frms may arise from for example developments in legal and other requirements changing circumstances
00:30:32 requirements changing circumstances related the organization's hazard and associated risks now stopping there according to that guidance the tmo should have had a system which allowed for a management review
00:30:42 review as opposed to external review or audit of its fire risk management systems at planned intervals would you agree that's a fair summary it is yes
00:30:51 is yes do you agree that the tmo didn't have such a system in place
00:30:57 um
00:31:03 uh
00:31:06 i i i i don't believe we had a formal system that had this management review but um the health and safety committee certainly did um
00:31:19 certainly did um review some of that information but as it stands there we didn't have a formal
00:31:28 formal you know this is a management review of fire safety systems in place no no and so the height of it was informal consideration of some of the
00:31:40 informal consideration of some of the matters set out in 83.2 i think so yes can you identify for us looking at a 3.2 the subjects that were considered albeit
00:31:52 the subjects that were considered albeit informally by you and the executive team looking at number a did you examine the status of actions from previous management reviews well
00:32:03 management reviews well if there weren't any presumably you can't look at actions if yes um change so that's a no b changes in external and internal issues that are relevant to the frms i think we definitely looked at those
00:32:16 i think we definitely looked at those when
00:32:16 when when issues came up when when changes came up
00:32:19 came up um externally or we had any issues internally i think we did look at those
00:32:27 those see information on the fire safety performance including those five trends set out under little c i i do believe we did look at some of those we may not have
00:32:39 those we may not have looked at interested party feedback um stopping there interested party feedback would you agree that included the views of residents yeah that's that was the point i was
00:32:50 yeah that's that was the point i was about to make and that's not something you considered not in these reviews unless there was an issue raised specifically by
00:33:01 by a resident about a particular block or issue concern that they had how did you evaluate compliance with legal and other requirements
00:33:19 i think the only way i can answer that is
00:33:22 is that i would rely on janice as the technical person to um confirm that we were in fact complying with legal and other
00:33:33 complying with legal and other requirements and finally looking at opportunities and recommendations for continual improvement um i think that was something that did come up sort of regularly through um review of um
00:33:46 through um review of um the fire risk assessments in particular but i do think we looked at that yes can you help us as to why there was no
00:33:55 was no formal policy for uh carrying out a management review as recommended under past seven i i'm sorry i don't know why there wasn't a formal policy
00:34:06 formal policy and i agree there should have been did did anyone raise the need for such a formal management review during your time no and presumably it didn't occur to you either
00:34:16 either no i mean i would say i was doing parts of it but didn't realize that this document existed and this is what was required
00:34:30 just thinking through about the informal processes that were in place was there any sort of review either by the executive team by you or by mr black or
00:34:41 by you or by mr black or all of those parties of the information collected by the tmo in relation to its fire safety performance um well yes i mean we would
00:34:53 um well yes i mean we would um review the uh the fire risk assessment actions which are part of fire safety performance and in particular
00:35:07 and in particular at the health and safety committee we would look in quite a lot of um well sort of detail into the statistics of that and that information um also
00:35:18 of that and that information um also went to the executive team now we looking again sorry staying with 8.3.2 but looking at 8.3.2 c 3 it refers there to
00:35:29 8.3.2 c 3 it refers there to audit results um was there any audit worthy of the name of the fire safety performance by the tier sorry any audit by the tmo of its own
00:35:42 sorry any audit by the tmo of its own fire safety performance or fire safety management the we had a program of internal audits one of which was health and safety covering all the
00:35:55 health and safety covering all the health and safety and in that the the scope of that audit covered um fire safety um i can't remember all the details of
00:36:07 um i can't remember all the details of it but i'm aware that it did cover uh fire safety uh fire fire safety and it was about um uh the management systems for for health and safety thank you now were
00:36:20 for health and safety thank you now were you aware of a number of external audits carried out of the fire safety function uh in terms of the lfb doing their inspections and audits of buildings yes i was aware
00:36:33 and audits of buildings yes i was aware of that
00:36:34 of that more broadly than that miss matthews were you aware of a fire risk assessment of the tmos fire safety policy and procedures that had been carried out by salvas in september 2009
00:36:45 salvas in september 2009 um i was aware of some of the history before i joined but uh i wasn't i didn't see the salvus report until
00:36:59 i didn't see the salvus report until um after all of this uh occurred so after the fire uh well after the fire and so no one ever referred in discussions and janice ray never brought the salva's
00:37:10 the salva's audit to your attention she might have referred to it and referred to the fact that there was a limited assurance internal audit on health and safety and that a lot of work had gone on in
00:37:22 and that a lot of work had gone on in the past before i joined to improve the systems um and uh my understanding was in terms of the internal audit
00:37:33 the internal audit that had now got a a much better rating which i can't remember did you form the impression that miss ray's view of the salvus audit was that it was
00:37:45 of the salvus audit was that it was fair criticism that had been made or did you sense that she felt that the criticism was unfair no i think i think she was aware that it was a fair criticism and a fair report on
00:37:57 criticism and a fair report on the the health and safety systems at that time
00:38:00 that time and were aware of a safety management review carried out by mad matt hodgson in 2013.
00:38:05 in 2013. uh i was aware of it but i i didn't see the details of it and you never had calls to read it no was it ever referred to in
00:38:16 no was it ever referred to in discussions by janice ray or indeed anyone
00:38:17 anyone else who predated you um
00:38:22 anyone else that predated me predated your time who had been at the tmo before you joined well i wouldn't no people who'd been still employed at the tmo
00:38:33 still employed at the tmo yes like janice rhodes yes sorry we've been there before you joined yes yeah i mean and janice would have referred to it because i was aware of the training program that
00:38:44 i was aware of the training program that has occurred and some of the actu other actions that that reported identified but my understanding there was again a number of those were already in place
00:38:56 number of those were already in place and moving forward presumably you would have been aware of the rbkc audit and health and safety it was carried out in 2016 during your tenure yes
00:39:11 is it fair to say that you didn't read audit reports that predated your start at the tmo in june 25th i might well have read the health and safety
00:39:21 safety one that that had limited assurance thank you because i would have read it alongside the um scope for the audit in 2016.
00:39:34 um scope for the audit in 2016. now um are you aware of a set of regulations called the fire safety employees capabilities england regulations 2010 uh i'm not sure that i am is i don't
00:39:46 uh i'm not sure that i am is i don't know then it's a no now regulation two provides this and if we go to the documents you've got in front of you h o m zero two five seven three seven
00:40:17 we don't necessarily have to have up on the screen it provides every employer must in entrusting tasks to employees take into account their capabilities as
00:40:28 take into account their capabilities as regards health and safety so far as those capabilities relate to the fire now bearing in mind that you are unfamiliar with the obligation how did you take into account that the
00:40:39 how did you take into account that the fire safety capabilities first of all of someone like janice ray um well i was aware of janice's uh qualifications and um the experience that she'd already
00:40:52 and um the experience that she'd already got
00:40:53 got in the role um and uh from working with her i was well aware that she was a very competent person in relation to fire safety um and also i was aware
00:41:07 um and also i was aware uh when i joined that um carl stokes was in place
00:41:10 in place and she used him as a consultant uh not just for the fire risk assessment program
00:41:18 program but if there are any issues relating to fire safety so um as in terms of janice ray that's how i had assessed her capability and
00:41:30 i had assessed her capability and competence was there any central record held by the tmo of the fire safety capabilities of relevant employees such as janice ray or contractors such as car stakes
00:41:41 or contractors such as car stakes i'm not aware of a central register i am sure that within janice's um hr record uh it would be recorded
00:41:53 um hr record uh it would be recorded her training and her qualification uh the various qualifications she'd got and the training that she'd done that would be recorded is it right to say that you had no cause
00:42:04 is it right to say that you had no cause to check whether she had the relevant qualifications because she'd impressed you by the means she carried out her job i'm sure when i joined i would have looked at her hr information as i did with all my
00:42:17 hr information as i did with all my new team members um would have been aware from that record of the qualifications that she got thank you
00:42:24 you or had thank you now i want to turn on to a separate topic now which is competency criteria for fire risk managers
00:42:31 managers and if i could ask you to go to page five of the competency criteria for fire risk managers which can be found at f s f quadruple zero double zero four one
00:42:43 quadruple zero double zero four one forward slash five there we go in section three comp is headed competency of fire risk manager and there is advice for uh varying size of organizations
00:42:55 uh varying size of organizations and if we look at the fourth paragraph it starts with the words for large organizations and it says this for large organizations and certainly those with extensive estate portfolios
00:43:06 estate portfolios fire risk management will be a complex role and should be undertaken by a competent dedicated fire risk manager now bearing that in mind given that there were 650 blocks in the tmos estate
00:43:18 there were 650 blocks in the tmos estate did you at the time consider that you had sufficient resources within the health and safety team to manage fire risk without a dedicated fire risk manager
00:43:30 probably at the time i i would have done um only because uh janice wasn't at that time advising me that that was uh
00:43:42 that was uh a concern or an issue to her but you know subsequently i think you know it's it
00:43:49 it's it it's fairly obvious it would be advisable and obviously appropriate to have a dedicated fire risk manager i i didn't know that at the time
00:44:00 at the time and during your time at the timber you never had cause to consider the benefits of appointing a dedicated fire risk manager no can i now turn to
00:44:12 no can i now turn to rbkc's role and in relation to its monitoring of health and safety in particular now can i ask you to look at janice ray's first statement to the inquiry which can be found at tmo quadruple zero
00:44:26 tmo quadruple zero zero eight nine zero forward slash thirty seven and i could ask you to look at paragraph
00:44:37 and i could ask you to look at paragraph 164
00:44:40 164 it says it was always my understanding that the rbkc retained a monitoring obligation under the modular management agreement which was exercised by its corporate health and safety advisor and its main health and safety coordinating committee
00:44:51 health and safety coordinating committee which was which was succeeded by the byboro health and safety committee first of all were you aware of rbkc's monitoring obligation uh i was yes did you ever have calls to
00:45:02 uh i was yes did you ever have calls to consult the mma um about this specifically no but i had looked at the mma on something else
00:45:13 something else thank you did you ever meet rbkc's corporate health and safety advisors gary mann until 2015 and samaya yakub from january 2016. no those names don't ring a bell at all
00:45:27 no those names don't ring a bell at all no did you meet anyone else from rbkc to discuss oversight of performance by the tmo of its health and safety obligations health and safety was discussed at the
00:45:39 health and safety was discussed at the joint
00:45:40 joint management meeting with rbkc i did not attend any corporate health and safety meetings with rbkc
00:45:53 were you ever pressed on particular questions relating to health and safety by anyone at rbkc whether it's laura johnson or councillors
00:46:02 we would have been asked questions by councillors that that may have come up from residents in their area
00:46:13 residents in their area and in fact there there were a few while i was there um and laura johnson would have uh asked us about
00:46:21 us about um health and safety performance uh when we were reviewing the annual report with her you've met you've used the formula would have what she did sorry that's what i meant
00:46:32 what she did sorry that's what i meant yeah politics we take that as meaning yes
00:46:34 yes yes now gary mann who's the corporate health and safety advisor rbkc until 2015
00:46:40 2015 he said in in his witness statement we don't need to go to it but the references are bk trouble zero five double four one four forward slash four at page eight paragraph thirty six
00:46:51 paragraph thirty six said this and i quote there was no formal process in place which required the corporate health and safety team to attend at the tmo offices and check them for health and safety compliance or call for their policies
00:47:02 compliance or call for their policies and procedures to be checked for compliance do you agree with that statement there was no formal process in place i agree do you know why there was no formal process i don't no because i believe there
00:47:13 i don't no because i believe there should be
00:47:14 should be did you have any reason at the time to call for a formal process
00:47:19 no now samaya yakub uh mr man's successor has also provided a statement to the inquiry she said at page eight of paragraph 35 of that statement and the
00:47:30 of that statement and the reference is rbk trouble zero five double four five six forward slash eight we don't need to go to it but she said this and i quote corporate health and safety did not routinely monitor or audit the general
00:47:42 routinely monitor or audit the general safety arrangements for the tmo i understood that tmo was audited by rbkc's auditing department who were on occasion assisted by deloitte i do not recall seeing any audit reports in relation to the tmo or
00:47:54 audit reports in relation to the tmo or hearing of any significant issues as a result of the audits did samaya yakub ever seek to exercise a monitoring function in relation to the performance by the tmo of its health and safety duties not that i was aware of
00:48:06 safety duties not that i was aware of did anyone to the best of your knowledge at rbkc
00:48:10 at rbkc challenge the tmo over the exercise of its health and safety duties uh not that i'm aware of and presumably if someone had made that chance of
00:48:21 if someone had made that chance of janice ray she would have reported that she would have done yes can we now turn to consider the corporate risk map um first of all what is the point of a corporate risk map
00:48:33 corporate risk map what is the point it's to bring up the well to
00:48:36 well to to document uh and um identify the key strategic risks for the business and the responsibility
00:48:48 the business and the responsibility for any mitigating actions and when you joined the tmo did you read the timo's corporate risk i did yes now can we look at an example of the
00:48:56 of the risk map and it's dated the 16th of march 2017 and that can be found at tm00899699 if we can look at risk number one
00:49:13 if that could be amplified serious number one
00:49:19 i'm sorry it's maybe one of those documents so the greater you expand it the less clear it comes but take it from me it says failure to comply with statute and regulation procurement legislation data protection equality
00:49:29 equality and diversity financial and internal controls safeguarding probity bribery and fraud now presumably it can't come as any surprise to you that failure to comply with health and safety
00:49:40 safety is a uh regarded as a risk do you agree yes can we look at the column which is fourth along from the left hand side headed
00:49:51 left hand side headed risk identified and explanation apologies that too is indecipherable i'll read it out to you thank you poor organizational governance leads to
00:50:02 poor organizational governance leads to failings in the areas of substantial or sustained breach of statutory or regulatory obligations failure to appoint the right contractors limits ability to deliver programs
00:50:13 limits ability to deliver programs risk of contractor challenge with financial penalties risk of under recovery of leaseholder service charges legal challenges can result from poor financial controls and poor safeguarding issues
00:50:24 issues reputational damage can arise from mismanagement of any of these issues now i think the first point is that poor organizational governance leads to substantial or sustained breach of statutory or regulatory obligations
00:50:36 of statutory or regulatory obligations uh presumably you'd accept that as a risk
00:50:38 risk yes and the reverse could equally be true that breach of stature or regulatory obligations may arise through poor organizational governance as well yes
00:50:48 yes and the second point failure to appoint the right contractors you are aware of the need to control that particular risk were you yes how did the tmo ensure that in relation to fire safety
00:51:00 relation to fire safety it had appointed competent contractors um i in terms of uh appointing contractors for fire
00:51:11 uh appointing contractors for fire safety again that would be uh in the responsibility of um the contracts management team and um peter madison would have been overall responsible to ensure that
00:51:25 overall responsible to ensure that we had
00:51:29 the right contractors with the right qualifications the other thing that we did to towards uh i can't remember when he joined but we had
00:51:40 we had an interim procurement manager who um helped to ensure that the procurement process
00:51:47 process ensured that we knew what what level of qualification contractors had what their experience was and what their
00:51:58 what their experience was and what their their expertise was can we look at risk number five
00:52:07 which says failure of health and safety in relation to the services that we deliver to residents staff in the work environment and contractors in the delivery of works that appears to include fire safety would you agree yes
00:52:19 would you agree yes and if we read along to the left under the column risk identified an explanation it says this serious injury or death of a resident staff member contractor customer or member of the public
00:52:30 member of the public potential prosecution by health and safety executive including terrorist activity would you accept that's a clear recognition of the importance of the risk not least the prospect of a health and
00:52:41 not least the prospect of a health and safety prosecution yes but equally and perhaps more importantly the risk of serious injury or death yes and to put it bluntly the consequences of a failure to manage health and self-safety duties
00:52:52 self-safety duties may result in serious injury yes can we look at the column-headed existing control measures mitigation or elimination slightly further along
00:53:03 further along and it says there's health and safety committee meetings every two months involving et and smt members so executive team and senior management team members where fire risk assessments and associated
00:53:15 fire risk assessments and associated actions water quality and asbestos reviews are monitored resulting actions are monitored and audited internal audit also monitor and report
00:53:24 report emergency planning tests in real events and has been reviewed as a consequence so monitoring of fras and associated actions is considered to be the existing control measure for fire safety yes and the resulting actions are to be
00:53:37 yes and the resulting actions are to be monitored presumably by executive team and the senior management team yes
00:53:42 team yes who was to carry out the auditing uh um
00:53:49 you talk about the internal oh resulting let's deal with it sorry resulting actions are monitored and audited that's that's what you're referring to um uh i think the understanding was that that
00:54:02 i think the understanding was that that was a
00:54:02 was a um a self-audit that um we would um if you like um review
00:54:12 the process and the resulting actions and our performance our own performance in that through the health and safety committee
00:54:23 health and safety committee so there would be no external review for example by rbkc the only external review would have been through the internal audit process can you remember was there any specific
00:54:34 can you remember was there any specific internal or indeed external audit of the monitoring of fras or indeed the entire fra process it not specifically as i said it was part
00:54:45 not specifically as i said it was part of
00:54:45 of the overall health and safety internal audit
00:54:50 audit now under the residual risk column it says this
00:54:53 says this actions arising out of assessments and inspections not done in a timely manner would you agree that clearly set out actions needed to be done in a timely manner
00:55:04 be done in a timely manner absolutely the person with who's fixed with responsibility for this risk is dfs that's the director of financial services yes that's you yes and you're aware that a failure to
00:55:16 yes and you're aware that a failure to manage this risk could lead to serious injury or death absolutely did you ever set out a specific departmental risk map i.e for your department including health and safety which included
00:55:27 and safety which included health and safety risks um [Music]
00:55:30 [Music] i can't i thought we had but i actually can't remember whether we did we may have started that risk map but i i can't remember
00:55:41 i can't remember i thought we had you certainly have no memory of a finalized adopted and applied risk map for your department is that a fair summary is a fair summary
00:55:54 were you or any of your managers trained in risk management and how to manage the risks identified in the risk map um i i'm
00:56:04 um i i'm i'm not sure whether we'd had any specific
00:56:08 specific training um but uh and i can't i can't say whether my managers has had that training before i joined
00:56:17 joined um but i did make it clear to them the importance of uh the risks with that they were um responsible for
00:56:28 that they were um responsible for that they yes that they were responsible for were you trained is the bit of the question you haven't answered oh sorry um i've i have had training in risk
00:56:39 i've i have had training in risk management prior to joining the the tmo and have had responsibility for corporate risk maps and risk management now can i turn to the uh separate topic
00:56:51 now can i turn to the uh separate topic of the tmos health and safety policy which you referred to in earlier answers now can we look at your second statement which can be found at tm0087380
00:57:02 which can be found at tm0087380 and paragraph four
00:57:10 thank you
00:57:14 now there you say and i quote the tmo's main policies in relation to fire safety were the health and safety policy and tmo for our safety strategy the fire safety strategy was being reviewed and updated during the time i was at the tmo
00:57:26 updated during the time i was at the tmo with the final draft being presented to the health and safety committee on the day before the file on the 14th of june 2017.
00:57:33 2017. now can we look at the health and safety policy first which can be found at
00:57:38 tm01024402
00:57:47 first of all did you read
00:57:50 actually i should have this is the 20th you can
00:57:53 you can exp sorry um not expand it you see the date of
00:57:56 date of february 2016. uh were you involved in the preparation of that policy is it post dated you're joining the tmo the the policy existed we reviewed it
00:58:07 it in february uh final review february 2016.
00:58:11 2016. and did you participate in that review i did and what was your contribution to this policy um the main thing was about um the responsibilities and and
00:58:22 um the responsibilities and and roles and clarifying and making more concrete your own response yes and to the best of your recollection that was the significant change that
00:58:33 that was the significant change that you made that was the significant change i made yes now if i can ask you to look at paragraph 1.2 it says this the legal and operation
00:58:42 operation sorry the legal operational financial responsibility for the management of health and safety rests with the chief executive of the tmo and each director and manager is responsible for the implementation execution control and monitoring of this
00:58:54 execution control and monitoring of this policy as relevant to their area of business
00:58:57 business so the an effect mr black was ultimately responsible for health and safety is that fair
00:59:03 that fair yes and you as director in charge of health and safety were responsible for the implementation execution control and monitoring of the health and safety policy i was yes now if we go on to paragraph
00:59:14 i was yes now if we go on to paragraph 1.4 it says we will ensure that all persons are competent to carry out the duties asked of them and will provide adequate information instruction training and necessary supervision we'll employ a health and safety professional who will be responsible for
00:59:26 professional who will be responsible for providing advice on all health safety and welfare matters now
00:59:31 now that means it would appear that you were responsible for ensuring that all persons were competent to discharge their health and safety obligations is that right as it's written there yes that that's what it says yes
00:59:43 what it says yes so you were yes to discharge that function effectively you too would have to be competent to discharge our health and safety duties would you agree with that
00:59:51 that i would and you were to ensure that adequate information instruction training and necessary supervision would be provided to all employees
00:59:59 employees is that again correct yes and would that include ensuring that you yourself were adequately trained it would yes was there any policy document which set out the competent
01:00:10 document which set out the competent standards required or the training requirements required for those who had key roles in the tmo's management of health and safety i don't think there was a document do you know why not i don't
01:00:22 a document do you know why not i don't i think did anyone raise that particular issue when this policy was reviewed i i don't think so no
01:00:32 can we did you say a moment ago that you think there should have been such a document
01:00:35 document i do yes i think it it needed that to support this statement thank you can we turn to paragraph 3.3 on page four please
01:00:51 again apologies for reading this out miss matthews as the managing agents for kensington chelsea's housing stock the tmo shares responsibility with rbkc for the provision and maintenance of a safe and
01:01:03 provision and maintenance of a safe and healthy environment for the residents it is therefore important that we continue to work closely with our bkc in the area of health and safety to facilitate this the health and safety team will continue to represent the tmo
01:01:15 to represent the tmo on the bibura corporate health and safety committee which is responsible for the coordination and promotion of health and safety measures across our bkc and hammersmith in fulham and for monitoring compliancy
01:01:26 monitoring compliancy um first were you aware that the tmo shared responsibility with rbkc for the provision and maintenance of a safe environment for residents yes how did shared responsibility work in practice um
01:01:38 practice um well i'll be casey um obviously owned the stock as i mentioned before
01:01:44 before and um the tmo was the managing agent any works done to the properties were they
01:01:53 they the um money for that was provided by rbkc
01:01:57 rbkc so their their role was to provide sufficient funds uh to enable the works required to be completed
01:02:08 the works required to be completed at any time during your tenure did you have reservations that the funds provided were sufficient to discharge health and safety obligations
01:02:17 i think our budget was restricted in terms of the work that was required on some of the buildings and therefore it on an annual basis
01:02:30 and therefore it on an annual basis this is and and therefore some of the works perhaps were not done as quick as they should do because the funds weren't there so when you say restricted is that a different way of saying there was a budget
01:02:41 budget it was budget yes
01:02:45 mindful that there will be a budget did you have any concerns that the budget had been drawn too tightly which was endangering the proper performance of health and safety obligations by the tmo
01:02:57 obligations by the tmo um i i wasn't sure that it was too tight in relation to health and safety
01:03:04 safety because if there were specific requirements which we couldn't manage within our existing
01:03:11 existing annual budget we would refer back to rbkc for additional funds for instance the discussion about replacement doors
01:03:23 replacement doors a replacement door and self-closure program
01:03:27 program when we started to talk about that after the adair fire put bluntly was there any time when you asked for more money for health and safety matters and the council said no
01:03:38 i don't think so no presumably that would spring to mind if they had said no and you'd asked for it yes i mean they the only time they've
01:03:49 yes i mean they the only time they've said no
01:03:50 said no is that is is not to do a program in three years but to do it in five so you could argue that's a no but that was a
01:03:58 was a no not now sort of thing understood so was rbkc's contribution made only via the byboro corporate health and safety team if it
01:04:09 corporate health and safety team if it had anything to contribute on the substance of health and safety matters um i i believe it came up at the any health and safety matters
01:04:20 matters and rbkc's role would have come up when we discussed it at the joint management meeting and i believe that the asset management
01:04:31 believe that the asset management meeting we also had with rbkc we would have raised about health and safety matters on on properties then thank you did you ever
01:04:43 properties then thank you did you ever attend the buy borough corporate health i didn't attend that one no did you yourself have any liaison with health and safety personnel rbkc on health and safety matters uh i don't think so no
01:04:58 did gary mann or samaya yakub ever attend tmo health and safety committee meetings that you're aware of no not in my time
01:05:06 and you don't remember either or both of them intervening on any health and safety matters i don't remember that no would you have stuck in your memory if they had done i think you probably would
01:05:17 they had done i think you probably would can we go next to paragraph 6.1 which is contractual management
01:05:24 i think you possibly answered my question here but just for the sake of completeness uh 6.1 sets out the vetting of contractors for competence and adequate resources
01:05:36 resources yes and in essence your answer to the question who within the tmo vetted contractors for competence that would be the contract contract management team and through the procurement process
01:05:47 procurement process that i mentioned and the procurement manager that our interim procurement manager looking at that question slightly differently how would the tmo satisfy itself as the
01:05:59 how would the tmo satisfy itself as the competence of contractors in relation to health and safety matters is that something that would be purely within the jurisdiction of contract management or would it be within janice's remake no it would if if
01:06:11 no it would if if it was a health and safety contractor then janice would be involved and would be um uh
01:06:22 involved and would be um uh she would review the um tender documentation as well to ensure that these the organization was competent uh to do whatever it was we wanted to do
01:06:35 uh to do whatever it was we wanted to do i mean i was thinking here specifically or in relation to fire stopping um but if it was a contractor to do um repairs but
01:06:47 um repairs but i can't think of a particular contract but but one that wasn't specifically health and safety then that would be dealt with by the contracts manager and their role was to ensure
01:06:58 ensure that they understood the organization's health and safety policy thank you now can i take you next to paragraph
01:07:09 to paragraph 10 which is at page six and it's to do with fire safety and emergency procedures and we see their 10.1 fire risk assessments are undertaken in workplaces and with within the communal areas of
01:07:20 and with within the communal areas of residential blocks as required and systems are in place to protect staff contractors and residents etc from the risk of fire managers are responsible for ensuring that workplace housekeeping is in good order and that smoking is not
01:07:32 is in good order and that smoking is not permitted in any tmo workplace where necessary automatic fire detection portable firefighting appliances dry rising firefighting mains emergency lighting and other fire safety measures are installed and maintained in
01:07:44 measures are installed and maintained in the workplace in other locations designated staff members are appointed and regularly trained to act as file marshals fire marshals will take control in the event of any of our workplaces requiring evacuation um would you agree
01:07:58 requiring evacuation um would you agree that uh and particularly bearing in mind the last sentence there that the weight of this particular provision
01:08:06 provision is on workplace fire and safety and the relevant procedures uh that that is yes that doesn't appear certainly to my reading to be much considerate of the
01:08:18 reading to be much considerate of the particular issues affecting tmo residents and fire safety is that a fair observation in that part of it yes the part of it under the heading fire safety
01:08:29 fire safety and emergency procedures yes the this is the health and safety policy
01:08:36 for the organization so
01:08:40 that's why this is looking at workplaces you didn't think that the organization included
01:08:49 included buildings managed by the tma i don't think that's what this document was intended to cover um and that the fire strategy covers
01:09:01 um and that the fire strategy covers uh the the properties and the residents just following on from that answer can we go back to paragraph 3.3 at page four
01:09:16 as managing agents for kensington chelsea's houses the tmo shares responsibility with rbkc for the provision
01:09:23 provision and maintenance of a safe and healthy environment for the residents bearing in mind that
01:09:31 would you want to reconsider the answer you've just given in relation to paragraph 10.1 to go back to 10.1 at page six because
01:09:42 to go back to 10.1 at page six because it seems
01:09:43 it seems bluntly the scope of this policy is deliberately aimed to embrace not only employees but also residents of the tmo
01:09:54 that's how it appears from from that earlier paragraph
01:10:01 but this you're you're correct in saying that this is clearly aimed at workplaces rather than um buildings and and residents well let's follow
01:10:13 and residents well let's follow that through and look at it it's a bit both isn't it because if you if you look at the opening to paragraph 10 1
01:10:21 10 1 it refers to the commonal areas of residential blocks and the protection of residents amongst others
01:10:28 others so it starts by being quite broad um and then it tends to go on to direct itself more to employees rather
01:10:39 direct itself more to employees rather than residents
01:10:42 yes that's uh
01:10:47 you're right it does it starts with um covering
01:10:50 covering residents but then looks at workplaces i i can't answer that when you when i read it initially it seemed okay
01:11:03 when i read it initially it seemed okay because i read it alongside the fire strategy but um you're right yes so it might have been an assumption you made that the health and safety policy applied at least predominantly to staff rather
01:11:15 at least predominantly to staff rather than residents that's how it appears now if that is so can we look at 10.3 which says employees with disabilities have their own individual personal emergency evacuation plan which is
01:11:26 emergency evacuation plan which is regularly reviewed and where necessary their colleagues are trained and safe use of the evacuation chair
01:11:32 chair were you aware of the concept the notion of a personal emergency evacuation plan when this policy was reviewed and signed off uh yes i was
01:11:43 now 10.3 makes clear that peeps are required for employees with disabilities would you agree yes and that those policies would be reviewed regularly yes now the policy makes no mention of the need for peeps for residents would
01:11:55 the need for peeps for residents would you agree with that yes or of disabled residents yes can you help us understand why such residents were omitted from this policy um again i think this this appears that
01:12:08 um again i think this this appears that it's related to staff in the workplace um and that we haven't quite rightly as you say looking at it now mentioned
01:12:19 looking at it now mentioned residents however in relation to personal emergency evacuation plans for residents
01:12:26 residents um the policy in our buildings was a stay put and defending place policy
01:12:34 policy and therefore we had not addressed personal emergency evacuation plans
01:12:42 and was that reasoning expressly considered as part of the review process that culminated in this health and safety policy for for residents
01:12:53 and after the event rationalization for its omission no i i don't know why it that it appears that this is for aimed at staff rather than
01:13:05 for aimed at staff rather than residents can i just ask you you say that the
01:13:10 that the you you had a stay put strategy yes but did did anyone think about the fact that an individual person a disabled person
01:13:23 person a disabled person might need to evacuate from his or her flat or the floor on which his or her flatten is located even if everybody else in the building was able to stay put in their flats
01:13:35 was able to stay put in their flats um in terms of the residents uh in the in the buildings um we were aware of uh some some residents
01:13:48 aware of uh some some residents vulnerabilities only if either they'd advised us or the uh neighborhood management team had managed to uh acquire that information through
01:14:00 uh acquire that information through through various so i understand that but my point is a slightly different one you you were seeking to explain the absence of any reference to peeps for residents yeah by reference the existence of a state
01:14:12 by reference the existence of a state put policy but i was just wondering whether any it had occurred to anyone that even in the context of the state
01:14:23 that even in the context of the state policy generally some resident or residents might need to evacuate if the fire for example was in there flat or had escaped and neighbors flat into the lobby and
01:14:36 and neighbors flat into the lobby and was threatening their flat and might have difficulty in doing so um i i don't think we had considered that aspect
01:14:49 considered that aspect as we probably should have done yeah right thank you so that might be an appropriate point subject to your approval for the afternoon break uh yes all right well we have a break during the
01:15:00 well we have a break during the afternoon
01:15:01 afternoon uh miss matthews and uh i think that's a good time to take the break today thank you we'll resume it 25 to four please
01:15:09 please and i must ask you on this and other occasions when you leave the room during your evidence not to talk about it or evidence to anyone uh once you're out of the room okay all right thank you thank you very much
01:15:20 right thank you thank you very much would you like to go to the usher please
01:15:30 all right thank you very much
01:34:51 thank you would you ask this masters to come back in please
01:35:06 all right ready to carry on i am thank you so take a moment for some water yes i'll just pour some water
01:35:17 thank you yes thank you when you're ready mr kennedy thanks sir ms matthews can we now turn to the timo's fire safety strategies uh now before we go through uh those strategies is it correct to say that the
01:35:28 strategies is it correct to say that the temo had
01:35:29 temo had one and one alone fire safety strategy to cover its entire stock yes now can we look at the fire safety strategy you exhibited to your statement and that can be found at tm008
01:35:45 and if we can turn to page 15.
01:35:54 there we go and we see the date at the bottom is november 2013. was that the version that was current when you joined the tmo uh yes and when did you first read it
01:36:05 yes and when did you first read it uh uh probably when i first joined i can't actually remember when i did but it would have been early on when i joined the organization can we go back
01:36:16 joined the organization can we go back and look at section 1.4 thank you which says this strategy document enables us to outline the
01:36:28 document enables us to outline the measures we have put in place not just to comply with fire safety legislation and best practice but more importantly to minimize the risk of fire throughout the housing stock
01:36:36 stock specifically we are committed to reducing the risk of an outbreak of fire and also the risk of a fire spreading within a building but also spreading from one building to another now the intention was for this document to be the overarching
01:36:48 this document to be the overarching strategy which outlined the tmo's approach to fire safety is that a fair summary yes and it was written by janice ray i believe so in it was before my time so i'm assuming
01:37:00 in it was before my time so i'm assuming it was
01:37:01 it was and was it a document to which you made regular reference or not at all oh no i did
01:37:06 did i did look at it quite regularly can we look at section five on page two and if we just look at some of the bullet points under section 5.1 at the bottom of that page
01:37:18 bottom of that page we see program of regular estate inspection risk assessments and monitoring by neighborhood staff and health and safety staff specifically inspections ensure that combustible items and storage are not present in the communal areas
01:37:29 present in the communal areas fire doors are operating effectively emergency lighting is maintained final exit doors are operational signage has not been removed or defaced wet dry riser cabinets have not been
01:37:40 wet dry riser cabinets have not been tampered with any communal area repairs have been completed to satisfactory standard etc all defects repairs are reported immediately by mobile telephone to the customer services center who instigate the repair repairs to fire
01:37:52 who instigate the repair repairs to fire doors self-closures etc are given priority
01:37:55 priority so a program of regular estate inspection risk assessments and monitoring by neighborhood and health and safety staff what's risk assessments have been referred to here so far as you understand it
01:38:07 the inspections or the risk assessment which bit are you referring to because this is about a series of um inspection
01:38:18 this is about a series of um inspection and
01:38:18 and inspection regime well this is the question i'm asking you miss matthews you're the one who referred to it regularly sorry can i go back to the start of that
01:38:29 can i go back to the start of that bullet point please this yeah i'm sorry uh regular in estate inspections risk assessments and monitoring the the regular estate inspections were
01:38:42 the the regular estate inspections were done
01:38:43 done mainly by the neighborhood staff the health and safety staff would do the risk assessment and the monitoring of the
01:38:57 actions understood uh we see the question of repairs highlighted here yeah the repairs to fire doors self-closers etc and they are given priority can you help
01:39:08 and they are given priority can you help with whether that referred to commonal doors
01:39:10 doors or all doors across the tmo stock i believe it was for all doors across the stock
01:39:17 the stock and to the extent to which you were aware were those repairs in fact given priority uh as far as i was aware they were
01:39:26 were now if we can turn over the page to page three and look at the third bullet point which states regular fire
01:39:33 fire risk assessments
01:39:38 and it says regular fire risk assessments fras and reviews and a prioritized approach to progressing action plan items what were the reviews referred to here can you help us
01:39:49 can you help us um my understanding was that those were the reviews that we would do of the fire risk assessments um and and to
01:40:00 um and and to um apportion the work so they would be internal reviews of the fras carried out by mr stokes yes they would be and there's no mention here of time scales for implementing
01:40:11 here of time scales for implementing action plan items or to emphasize their completion in a timely manner to use the language of the corporate risk map can you explain that omission
01:40:24 the timing of the actions or the requirement for the timing of the actions is identified in the fra action plan and the fras themselves
01:40:37 fra action plan and the fras themselves give the
01:40:38 give the timing that the action should be completed by um but you're correct in saying that there is nothing about completing those in a timely manner was that timeliness
01:40:50 in a timely manner was that timeliness was it ever something that was considered as a necessary addition to the strategy for example uh looking at the issues that thrown up by the fra significant action problem
01:41:02 um it obviously wasn't because i think this
01:41:06 this is repeated in the same way it wasn't updated to say that in the 2016 one and hindsight you know it looks like it
01:41:17 and hindsight you know it looks like it should say something thank you now if we can look at the penultimate bullet point on page three
01:41:23 three which is entitled fire safety
01:41:27 thank you fire safety of resident staff and contractors will be considered at every stage of construction projects and will be reflected in construction stage plans risk assessments and method statements compliance with building regulations is
01:41:39 compliance with building regulations is paramount engagement with contractors to reinforce the need to ensure that all works are made good excuse me go to a fire resisting standard and the contractors adequately
01:41:50 standard and the contractors adequately train their operatives in order to facilitate this post inspections will also scrutinize this aspect of works who was responsible for ensuring compliance with that aspect of the strategy i.e
01:42:02 strategy i.e for ensuring that fire safety was reflected in construction stage plans risk assessments and method statements that would have fallen into the asset and regeneration team where the
01:42:15 team where the any construction uh or any um refurbishment or major works to the properties would have been managed and the contracts
01:42:26 contracts um that would have been set up accordingly for those works and who was responsible for ensuring that works were quotes made good to a fire resisting standard close quote
01:42:39 standard close quote uh that would be the responsibility of um asset management would health and safety have any role in that um that
01:42:50 that um that health and safety would have a role in ensuring that they are doing that that they are checking that the works are
01:43:02 compliant and that works are made good for resisting standards so health and safety would be responsible for post inspection checks on works being carried out
01:43:14 being carried out not not the post inspection works because
01:43:17 because post inspection uh you you you're not seeing what's going on uh health and safety would um review things as uh the cons
01:43:29 would um review things as uh the cons the works are going on to and and liaise with the asset management team to ensure that's happening the post inspections referred to there are the post inspections done
01:43:40 to there are the post inspections done by the
01:43:41 by the uh within the asset management team thank you if we can go to page nine and the stay put defend and play strategy and can we look at that please at the bottom you go
01:43:55 if we go to page 10
01:44:00 see 15.1
01:44:04 the fra confirms the appropriate evacuation strategy for the block overwhelmingly a state put defending place has been highlighted as the appropriate strategy for our blocks and the lfb have been made aware of this specifically this means that only the
01:44:16 specifically this means that only the residents in the flat where the fire breaks out are initially required to evacuate this is because the compartmentation between the flats and also between the flats and the common parts of the block are considered to be sufficient to
01:44:27 are considered to be sufficient to withstand fire for a significant period this is communicated to residents by a variety of means residence handbook website the link magazine etc so the evacuation state strategy is
01:44:38 so the evacuation state strategy is premised on a block by block basis is that a fair yes and the specific strategy will depend upon the fra for each block is that correct yes was there any system whereby the tmo
01:44:49 was there any system whereby the tmo defined and implemented fire safety precautions on a block by block basis uh fire safety precautions
01:45:02 uh fire safety precautions um we would have looked at uh the difference um in the the each block because he each each each
01:45:13 each block because he each each each block was built differently so you'll have different design of maybe communal areas or use of lifts or stair
01:45:25 or use of lifts or stair staircases and looking evacuation in particular here there appears to be no distinction between the different types of resins in a block i.e between those who are able-bodied for example and those who may have
01:45:36 for example and those who may have mobility issues no that's correct did you or anyone at the tmo consider whether the strategy should deal with a situation where the lfb changes advice from stay put to full or partial evacuation
01:45:50 put to full or partial evacuation uh on a permanent basis for a particular block you're talking about or just generally in any respect before the grenfell tower fire on the fort i i don't think we've looked at that
01:46:01 looked at that at all
01:46:04 uh can we go back to paragraph 43 of your first witness statement which is at tmo one double zero four double nine eight seven forward slash
01:46:13 slash nine and paragraph forty three
01:46:17 and you deal here with the adair tower fire which is at the end of october 2013 and the lfb made the decision to abandon the staple policy did you consider whether tmo should
01:46:28 did you consider whether tmo should inform residents what to do if as happened at the dare tower the lfb changed its advice
01:46:36 no we didn't because the lfb made that decision
01:46:39 decision the policy in that building was a stay put policy during the fire itself the lfb made the decision to evacuate the
01:46:51 lfb made the decision to evacuate the residents
01:46:52 residents and they initiated the evacuation tmo staff didn't no we're putting to one side who initiated the withdrawal of the policy
01:47:03 the policy did the turmoil consider at any stage following the dare tower fire of what ought to be done if a fire broke out and a disabled resident could not evacuate their flat
01:47:15 no i don't think so
01:47:19 can we look next at the policy governing flat entrance doors and that can be found at item 17 and if we go back to tm00830598 forward slash 11. we see a paragraph
01:47:33 forward slash 11. we see a paragraph 17.1.1 it says this one area highlighted in many fras was the need to investigate whether flat entrance doors and enclosed blocks were sufficiently fire resisting and self-closing in every case where the assessor could
01:47:45 in every case where the assessor could not be confident that the flat entrance door
01:47:47 door met the required fire safety standard or where he was unable to ascertain that any glazed transoms etc were adequately fire rated or resistant he highlighted these locations in the action plan now the policy
01:47:59 in the action plan now the policy highlights flat entrance doors as an area for concern is that a first that's correct uh specifically the need to investigate whether flat entrance doors were sufficiently fire resisting first of all yes and self-closing so yes
01:48:12 first of all yes and self-closing so yes can you assist with how the tmo was addressing both those needs when you joined in june 2015. my understanding was that there was
01:48:23 my understanding was that there was there had been a borough wide programme to replace flat entrance doors with
01:48:29 with fire resistant self-closing doors in 2011 and that our policy was to
01:48:40 that our policy was to check and inspect and if necessary repair or replace both door and or self-closer when the flat was void or we were doing
01:48:53 when the flat was void or we were doing major works or their door was damaged or in fact if the resident had raised a concern about the state of their their door now can we now move on to
01:49:05 their door now can we now move on to paragraph 24 on page 14 which governs fire procedures
01:49:12 and it says at 24.1 this staff who are not fully able-bodied who may need assistance to be alerted to the fire alarm
01:49:19 alarm or and or require assistance to evacuate from the office are required to have a personal emergency evacuation plan peep the h s team will meet with the individual and together they will complete a pro
01:49:30 and together they will complete a pro forma clarifying their specific evacuation procedure in some cases this involves the use of a lightweight evac chair and training of staff in its use and any additional assistance they will be
01:49:41 additional assistance they will be provided etc the peep will be reviewed on a regular basis and when the needs slash ability of the individual change in any way now as with the health and safety policy
01:49:53 now as with the health and safety policy there is no provision here for residents who are not fully able-bodied and who may need assistance to evacuate can you explain that omission um no i don't know why we didn't include
01:50:05 no i don't know why we didn't include something
01:50:05 something about that and as a consequence peeps were not generally used for residents in general needs housing is that right that's correct can we now look at the fire safety strategy that was in draft form
01:50:17 strategy that was in draft form presented on the 13th of june 2017. that can be found at seven three tm008733 seven eight
01:50:30 and if we look at paragraph two point two
01:50:33 two on the first page after the word residential blocks in the third line the following words have been added
01:50:46 the following words have been added namely
01:50:47 namely on a regular basis and that any significant findings and action plan identified in the assessment are progressed in a timely basis going back to my earlier question about
01:50:58 going back to my earlier question about timeliness why were these words added these words were added because i was finding that things were not being completed in a timely manner
01:51:09 completed in a timely manner and when i arrived there were a number of outstanding actions that have been outstanding for a very long time up to up to an over 12 months
01:51:19 months what does timely mean here is it timely by reference to the risk presented by the outstanding work or the absence of any particular measure how is it how is it calculated each
01:51:32 how is it how is it calculated each action
01:51:33 action would have a um a target requirement completion um and they needed to be completed within that that time that time frame
01:51:46 that time that time frame now if we can go to page 3 and item 5.1
01:52:00 and sorry we see the first bullet point
01:52:08 but under the words action plan items the following have been added and regular monitoring of progress with completion by the health and safety committee why was that added
01:52:20 was that added so with completion of this by the health and safety committee
01:52:28 are you with me yeah yeah i'm just reading it again to to to get my head around it um
01:52:36 one of the things that i wanted to make sure is that there was somewhere where this was actually being monitored and
01:52:49 we had so many outstanding actions that i wasn't sure whether the health and safety committee were actually monitoring the progress and ensuring the
01:53:00 monitoring the progress and ensuring the completion so that was added as a specific item so that's health and safety committee carrying out a monitoring function
01:53:11 function monitoring of progress yes and completion now can we go to the fourth bullet point from the bottom
01:53:23 and the last sentence has been added along these lines additionally the tmos fire consultant is regularly consulted during major works and liaisons with contractors
01:53:34 and liaisons with contractors consultants and undertakes inspection as requested
01:53:37 requested was that a statement of fact as opposed to policy i.e that a fire consultant would always be consulted during major works um
01:53:49 the intention was that the fire consultant would be required to be consulted on major works for all of them
01:53:59 of them and was that inserted because a fire consultant had been used on the refurbishment project of grenfell uh it will have been partly that but also partly the fact that we um felt that any of the
01:54:13 we um felt that any of the um construction works any of the major works that were happening needed to have the fire consultant consulted to ensure that um
01:54:25 consulted to ensure that um that that he was um well that he could comment on any of the fire safety issues in that building due to the changes we were making now
01:54:37 due to the changes we were making now looking at the next bullet point before we leave that bullet point the way that's expressed suggests that the tmo has a standing fire consultant is that what was intended that that's
01:54:49 is that what was intended that that's yes that's the fire consultant who was doing the fire risk assessments that's who that's referring to so it's not a tmo employee it's it's the consultant that we've
01:55:02 it's it's the consultant that we've employed
01:55:03 employed who's that that was carl stokes at the time that's just what i wanted to know okay
01:55:07 okay sorry i preempted my next questions um so
01:55:11 so just i just want to make sure you're not referring there to x over it's carl stokes
01:55:15 stokes now that that that particular reference would have been carl stokes because it refers the tmos fire consultant can you help us as to why that had been
01:55:26 can you help us as to why that had been included in the strategy specifically in relation to breaches in compartmentation there a specific reason why it was phrased in that way um sorry which which
01:55:38 um sorry which which we're looking at the same we're looking at oh sorry the next one sorry i confused you that the services of a third-party accredited specialist fire contractor have been procured yes and this contractor can be instructed to competently undertake work
01:55:50 instructed to competently undertake work on any breaches of compartmentation now why was that specifically included in the strategy and in particular the words relating to breaches of compartmentation
01:56:01 breaches of compartmentation um because on inspection in some of the buildings we had identified that there were um work that was required
01:56:13 um work that was required to improve the breaches of compartmentation and in order to do that we needed a specialist who actually was accredited to do
01:56:27 who actually was accredited to do that piece of work now can we go next to paragraph 14.4.1 under fire fra action plans
01:56:42 under fire fra action plans page 10.
01:56:48 now some of the wording in 14.41 has been updated but the final sentence has been newly added and it says to assist with this a report
01:56:59 and it says to assist with this a report is submitted with a breakdown of all actions by team and an age profile of all outstanding actions is also provided was that inserted because there'd been an issue regarding the completion of fra
01:57:10 an issue regarding the completion of fra actions by the tma it was now if we go to paragraph 15 next the stay put defend and play strategy the wording of 15.1 does not appear to us at least to be substantially
01:57:21 us at least to be substantially different
01:57:22 different but there is a new sub-paragraph at 15.2 regarding fire action notices and that sub-paragraph says this information on fire procedures has been communicated to residents by a variety
01:57:33 communicated to residents by a variety of means
01:57:34 of means letter to new residents information residence handbook on website articles in the link magazine etc however this has now been this is now being supported by fire action notices within the common parts
01:57:45 action notices within the common parts of the blog a program of fitting fire action notices so that residents visitors and contractors are informed about the fire procedure is underway can you explain why that edition had
01:57:56 can you explain why that edition had been made to the strategy um because it had been identified in uh uh um the adair fire risk assessment
01:58:07 adair fire risk assessment i believe it was a dare and we had a discussion about fire action notices
01:58:15 notices and we agreed that it was appropriate to have them
01:58:19 have them in every block and also on each floor did you examine the letter to new residents and verify for yourself the adequacy of the information provided to you
01:58:30 the information provided to you i did not can we look at a statement provided to the inquiry by daniel lewis who is a team administrator then a neighborhood coordinator from late 2016
01:58:41 late 2016 who joined the tmo in april 2015. we can find his statement at tm0080 762 and if we go to paragraph 8.
01:59:02 762 and if we go to paragraph 8. and what he says there is this from review of the attached welcome pack documents i cannot see that any fire safety advice was provided to new residents
01:59:10 residents although i note in the useful contact numbers word document that the tmo's website details were provided and they understand that the tmo's website contained fire safety advice
01:59:19 advice the useful contact numbers word document also provided new residents with the fire brigades number first of all are you aware of the packs he's referring to here the welcome packs
01:59:30 he's referring to here the welcome packs um if that uh i'm not sure i'm not sure what was in the welcome pack but i was advised that there was a letter outlining the fire um
01:59:42 a letter outlining the fire um safety uh in relation to their particular the new residents particular building and the strategy so i'm not sure whether
01:59:53 and the strategy so i'm not sure whether that was in the welcome pack or whether that was at the sign up now can we look at what he says about residents handbooks and that's a paragraph 14 of his statement over the page
02:00:04 page sorry two pages
02:00:09 thank you he says that this i have been asked by the inquiry to confirm if a residence handbook was provided to new residents at granville tower and if so to confirm if the resident's handbook formed part of the welcome pack
02:00:20 formed part of the welcome pack i joined the lancaster west office in 2016 and cannot recall that the residence handbook was part of the welcome pack i recall that when i joined the tmo i was told that the residence handbook had been a
02:00:30 been a work in progress for some time and was not finalized i do not recall that it was ever finalized after i joined the tmo did you check what information on fire procedures or general fire safety
02:00:42 procedures or general fire safety information was contained in the most recent version of the residence handbook i'm not sure that i saw the latest version of the residence handbook to so i can't answer
02:00:53 residence handbook to so i can't answer that
02:00:54 that well you can say that if you never saw it well if i never saw it i didn't check it
02:00:59 it did you check whether the handbook had in fact been finalized and sent to residents
02:01:04 residents i didn't check that no now can we look at what he says in relation to the fire safety letter and that's a paragraph 19.
02:01:18 he says this i've been asked to confirm if tiemo double zero 865-911 being the letter from janus ray with the subject line fire safety in your home was provided to
02:01:30 fire safety in your home was provided to new tenants at grenfell tower i cannot recall this letter being included within the welcome packs and my team would not have been responsible for sending the letter to residents
02:01:39 residents i do not know who would have been responsible for this did you ever seek confirmation that letter was in fact sent to new residents um the only uh
02:01:50 um the only uh thing that i would have um checked was with janice about whether um uh her identifying that there was a letter
02:02:01 letter that was going to new residents was actually going to new residents and i i don't know how that happened because that was out of my particular
02:02:14 because that was out of my particular area of responsibility my understanding was they were given that at sign up i don't know whether the welcome pack is the same as the information that tenants were given at sign up now
02:02:25 that tenants were given at sign up now can we
02:02:25 can we um return to the fire safety strategy itself
02:02:29 itself and if we go to tmo double double00830598 forward slash 11 and paragraph 17.1.1
02:02:43 now this is the previous strategy one we looked at earlier i think yeah and in the first sentence it read one area highlighted in many hr fras
02:02:54 one area highlighted in many hr fras was the need to investigate whether flat entrance doors and then closed blocks were sufficiently fire resisting and self-closing and if we can go to the updated draft strategy
02:03:05 strategy which is at tmo double zero eight four double two one zero forward slash ten
02:03:21 and look at 17.1.1 so it must be over the page apologies
02:03:30 it says our fire risk assessor is required to highlight any potentially non-compliant flat entrance doors for further assessment in addition access permitting he is required to assess a percentage of doors
02:03:41 required to assess a percentage of doors in each block to ensure that they are sufficiently fire rated and self-closing now in the original strategy the need for the tmo to investigate flat entrance doors is highlighted
02:03:52 highlighted in the updated draft strategy the onus has put on the fire risk assessor to assess a percentage of doors in each block
02:03:59 block would you agree yes i said the question that flows from that was there a deliberate and informed change in strategy requiring the assessors to check the percentage or was it always the case that you'd
02:04:10 or was it always the case that you'd understood it that the assessor was to check a percentage of dollars um i think the intention had been that the assessor
02:04:17 assessor in the original documentation that the assessor would would do that however that wasn't clear so what we're making sure here that it is absolutely clear
02:04:28 is absolutely clear what we want our fire risk assessor to do
02:04:32 do what the other question that flows from this was there any percentage of doors in each block that it would propose that the fire risk assessor
02:04:40 assessor should look at i can't remember if we had a
02:04:44 had a fixed percentage i'm sorry i can't remember that do you remember any discussions in meetings as to the extent of the sample exercise carried out by the fire risk assessor
02:04:57 carried out by the fire risk assessor no i can't remember now in the second paragraph looking at this draft strategy we have an excerpt of the building regulations
02:05:08 regulations and below that it says this in discussion with rbkc it has been agreed that the termo will embark on an inspection installation program to ensure that entrance doors to all
02:05:19 ensure that entrance doors to all tenanted flats are fitted with a self-closing device this program will be over a period of no more than five years will commence in this financial year and will be risk-based with the potentially
02:05:30 will be risk-based with the potentially high risk properties featuring at the start of the program to ensure that access can be obtained to all tenanted properties to complete this installation work an access procedure is being agreed with rbkc's legal services team
02:05:42 rbkc's legal services team in advance of the work commencing a copy of this access procedure will be available from the tmo health and safety team shortly again this issue of checking self-closing doors
02:05:52 doors arose as a result of the dare tower fire is that correct that's correct and the tmo needs to carry out the inspection installation program is that right that's correct and it was to be funded by
02:06:03 funded by rbkc over a five-year period that's correct
02:06:06 correct and the tmo were concerned about how to access properties to check whether the entrance doors did have self-closures is that right that's correct and hence the need to agree
02:06:15 agree sorry hence the need to agree an access procedure with rbkc legal services correct
02:06:22 correct now can i turn to a separate and distinct but linked issue and that's key performance indicators okay can we look first of all at a document from january 2016
02:06:33 from january 2016 and that's can be found at tmo10011825 which appears to set out the health and safety kpis
02:06:52 now if i might ask you just to scan that list of the kpis as they stood in january 2016.
02:07:02 we see gas servicing water quality lightning protection annual testing lifts electrical electrical again with props of valid test certificates
02:07:13 props of valid test certificates would you agree none of those concern fire safety that's correct that was the existing list
02:07:21 list and if we can look at section two and if we can see all of section two if that's possible
02:07:30 um we see some additional proposed kpis and i can tell you which ones they are it's 2.11. number of fires reported in
02:07:41 it's 2.11. number of fires reported in month
02:07:42 month 2.12 number of lfb deficiency notices a number of broadly compliant letters 2.13
02:07:48 2.13 enforcement notices 2.14 percentage completion of fras due for review in the month and over the page
02:08:01 fra actions completed
02:08:05 now were those proposed f kpis measured from the date of this document was that due to be the starting point january 2016 uh that was
02:08:18 uh that was the intention they were if you noticed that
02:08:22 that they were up for discussion as to whether we would include all these items um uh in the kpis we'll come on to that
02:08:33 uh in the kpis we'll come on to that okay so you can sort of um assist the panel more further more in more detail on that um but was the intention if they were accepted uh for these kpis
02:08:44 if they were accepted uh for these kpis to start to apply from financial year 1617 that was correct yes do you remember now how they were to be measured
02:08:52 measured was there much detail of the mechanisms for that and that was the next discussion about how and where we would find that be able to get that information some of
02:09:03 be able to get that information some of the information was relatively easy to get some of it would be
02:09:08 would be harder and we needed to discuss how we were going to get that information now there was an audit in 2013 which you referred to earlier in your evidence and the
02:09:19 earlier in your evidence and the follow-up in december 2013 and if we could look at the audit report first which is rbk quadruple zero zero three one three and specifically
02:09:31 zero three one three and specifically what it says under recommendations in relation to kpis on paragraph 10 on page 21.
02:09:43 and we've looked at this sorry over the page
02:09:46 page with paragraph 9.3 sorry so that was my thought we see audit noted at 9.3 that only a limited number of health and safety performance indicators are reported
02:09:57 indicators are reported and there is an absence of meaningful indicators for areas such as electrical inspections etc 9.4 in the absence of a full range of performance indicators for health and safety specific areas
02:10:08 safety specific areas there is a risk that management cannot monitor performance levels for these areas and take appropriate corrective action where poor or inadequate performance levels are identified and if we look down further below that
02:10:20 and if we look down further below that you see an emboldened text recommendation and then management response the recommendation is set out there appropriate performance indicators relating to health and safety should be developed by management and
02:10:32 should be developed by management and then the management response below that
02:10:36 says however it's been acknowledged it would be beneficial for the tmo to supplement this with meaningful health and safety key performance indicators and it says there are range of such indicators now being identified covering a range of areas including health and
02:10:48 a range of areas including health and safety inspections fra sorry i should say fire risk assessments reviews enforcement deficiency notices received number of accidents fires violence incidents percentage asbestos surveys completed and then going on
02:11:01 surveys completed and then going on percentage compliance on maintenance of fire equipment wet and dry rises fire extinguishers fire alarms sprinklers etc now looking at that some of the performance indicators that the tmo
02:11:13 performance indicators that the tmo management said were to be implemented in 2013
02:11:16 in 2013 were being proposed as performance indicators in january 2016. would you agree with that summary i would yes juno recognizing that you only joined in june 2015. yes
02:11:28 2015. yes um are you able to help us as to why nothing had been done about applying those accepted kpis between 2013 and january 2016. i don't know why it took
02:11:40 january 2016. i don't know why it took so long to identify and start reporting on them was the delay
02:11:46 the delay not a subject which was discussed when you came to consider these in january 2016.
02:11:52 2016. i can't actually remember
02:12:01 could we just look at a further discussion regarding these kpis after 2016 and go to the health and safety committee minutes from the 13th of june 2017 and you can go to tmo one double zero
02:12:13 and you can go to tmo one double zero one seven
02:12:14 one seven five four one
02:12:25 now if the document manager wouldn't mind just scrolling through the minutes just so
02:12:30 just so miss matthews can familiarize herself with what was on the agenda my essential point to you miss matthews will be that there doesn't appear to be a specific kpi item on the agenda and
02:12:41 a specific kpi item on the agenda and i'd just like you to review that just to see whether that's a correct point to put to you
02:12:52 no there doesn't appear to be a specific i'll just let you scan it through before giving a final answer
02:13:01 please tell the document manager when you want it change to the next page
02:13:06 there you can go next page
02:13:11 there's only that section that refers to performance but no reference there to kpis
02:13:17 kpis no i don't know why that wasn't well that's my question do you know why there doesn't appear to be any discussion of kpis looking at this this is a minute health and safety minute yes no
02:13:29 and safety minute yes no day before the fire itself you're correct although i note that in um the previous sections um where we've talked where there are sections on
02:13:40 sections on violent incidents and accidents for instance
02:13:43 instance there'll be the kpi information related to that
02:13:47 to that in the report that was associated so i think the issue is we didn't have a separate
02:13:55 separate here are all the kpis and and the numbers and the reasons we had individual reports on particular uh performance so i agree there wasn't
02:14:06 uh performance so i agree there wasn't the overall picture i suppose i can pull my point more bluntly it appears on the face of these minutes at least that the fire safety kpis were not monitored by the tmo following their proposed
02:14:18 by the tmo following their proposed implementation in january 2016. is that a fair summary of the position i'm not sure that it is because of the point i'm
02:14:25 point i'm i'm actually making so um again going back through the the report and the kpis the fire kpis related to
02:14:36 and the kpis the fire kpis related to the fire risk assessment actions and there was clearly a report on the performance of those because we picked that up under fire risk assessments um the there was a kpi
02:14:48 um the there was a kpi on violent incidents and accidents and that's picked up and the information in that particular report will have the numbers
02:14:55 numbers and what what those cases were in in the other
02:14:59 other fire uh area which was about um the number of enforcement notices or the number of
02:15:06 number of um deficiency notices those would get picked up in their section so i think i think the the issue is we didn't have a full here's the kpi report
02:15:19 a full here's the kpi report and then all the information against the explanation about the performance we didn't produce it as a performance a kpi performance document
02:15:30 document but what we did was have separate reports on on different air different key areas which is what these items on the agenda are
02:15:42 did you put this point differently to you but did you have uh specific monitoring just looking at these minutes as illustrative of the approach taken by the tmo
02:15:53 specific review of kpis for example in respect to fire risk assessments enforcement deficiency notices received fires
02:16:01 fires that that's exactly what i'm saying yes we would in individual items on the agenda
02:16:06 agenda so if if there were deficiency notices then there'd be there'd be a section on on enforcement and deficiency notices and we would report on those and the um
02:16:19 and we would report on those and the um appropriate actions thank you um so i've come to the end of that particular topic we are nearly at twenty past
02:16:27 past two twenty plus four rather the next topic is fire risk assessments which is substantial and my preference would be not to start it at 20 past four this afternoon but start
02:16:38 at 20 past four this afternoon but start it tomorrow morning how are you getting on with the witness um we are on track and certainly to finish our evidence at the close of business tomorrow within tomorrow within tomorrow
02:16:49 within tomorrow within tomorrow well i don't suppose you'd mind having a slightly early afternoon would you no i don't mind well i think in that case miss matthews
02:17:00 i think in that case miss matthews will call a halt there slightly on the early side but that's all right and we'll have to ask you to come back tomorrow yes but as you've heard from mr kenya he
02:17:11 yes but as you've heard from mr kenya he is confident that you will finish your evidence tomorrow thank you um so we'll resume at 10 o'clock please yes and again please remember what i said to you earlier not talk to anyone about your evidence or
02:17:23 talk to anyone about your evidence or anything relating to it yes overnight all right yes thank you very much we'll see you at 10 o'clock tomorrow
02:17:29 tomorrow thank you like to give the ocean now thank you
02:17:44 i'm still getting here 10 o'clock tomorrow then please thanks
02:17:59 you