TMO's closing statement defending their fire safety compliance, external wall assessment, and response to regulatory requirements
00:21:25 now the next statement is going to be made by mr agarose queen's council on behalf of the tmo and he's elected to make his statement uh remotely
00:21:37 uh remotely so the first thing i have to do is to ensure that we can see and hear each other well mr agarose i can see you
00:21:44 see you i hope you can see me can you i can hear you mr chairman i hope you can hear me i can thank you very much and we can see each other i hope yes thank you very much good thank you
00:21:55 yes thank you very much good thank you well you're going to make closing statement in module 3 on behalf of the tmo that is correct good afternoon mr chairman good afternoon panel members
00:22:07 afternoon panel members at the outset of these submissions the tmo wishes to reiterate that its deepest sympathies and condolences lie with the bereaved survivors and residents so we acknowledge the immense tragedy of
00:22:19 so we acknowledge the immense tragedy of the grenfell tower fire and nothing in these submissions is intended to diminish or detract from that tragedy
00:22:28 tmo witnesses gave evidence across all topics in module three of phase two and their ad and their evidence spanned many days they were questioned intensively and all matters relevant to module three
00:22:42 and all matters relevant to module three one thing the tmo invites inquiry to keep in mind when considering these submissions is that while the tmo continues to exist as a corporate entity this is for the purposes of assisting
00:22:53 this is for the purposes of assisting the inquiry as a core participant and in recognition of the fact that it may feature in future legal proceedings all the present directors are non-executive directors and none was
00:23:06 non-executive directors and none was imposed at the time that matters addressed in the inquiry were occurring considering this the submissions made on behalf of the tmo are by way of comment on the evidence which of course the
00:23:17 on the evidence which of course the inquiry may accept or reject but they should not be construed as the corporate views of the tmo as there is now no one corporate voice
00:23:28 as there is now no one corporate voice so the other thing to consider is that on some occasions under questioning tmo witnesses accepted that certain that a certain course of action or situation amounted to a breach of the rro
00:23:39 amounted to a breach of the rro and ultimately whether there was a breach of the rro in particular circumstances as a matter for the inquiry
00:23:46 inquiry and a witness's subjective view of whether there was a breach or not is not fully determinative of the issue the inquiry the tml also invites inquiries to be careful to avoid passing
00:23:58 inquiries to be careful to avoid passing judgment based on hindsight and submits it should have a clear idea clear eye to what was the state of knowledge in the industry at the time when deciding whether there was a breach or not
00:24:11 or not so also to say that a particular course of conduct or situation amounted to a categorical breach of the rro is problematic when the inquiry considers that its own experts frequently express
00:24:23 that its own experts frequently express conflicting views about how to comply with a given provision
00:24:28 provision the inquiry will be considering the ir that the inquiry will be considering the rro in detail in a later module we'll have to grapple with the question of whether the rro is and was fit for purpose and or requires substantial
00:24:40 purpose and or requires substantial amendment
00:24:42 amendment so can i deal first with topic two which is the tmo's obligations and duties under the rro and particularly the composition of the external wall as part of the rro
00:24:56 external wall as part of the rro an important issue covered by the inquiry was whether the composition of the external wall during and after the refurbishment fell within the terms of the rro
00:25:05 the rro therefore should have been considered as part of the tmos fire risk assessment colin todd gave important evidence on this topic during questioning he said that in his view which he considered to
00:25:17 that in his view which he considered to be representative of the wider view of the fire risk fire risk assessment trade the external wall did not fall to be considered under the rro as it was not a common part and the rro only applied two
00:25:30 common part and the rro only applied two common parts he pointed to the fact that a similar view was expressed by the then dclg in the immediate aftermath of the grenfell tower fire he said that prior to the shepherds
00:25:41 he said that prior to the shepherds caught fire he was not aware of fire authorities who took took a different view
00:25:46 view and cited the fact that a senior officer of lfb had said before the fire safety act came into force that external cladding was not yet part of the rro
00:25:57 of the rro he also did not think that the external war formed part of the compartmentation and so did not fall to be considered as part of the rro from that perspective either
00:26:08 either colin todd said that when he had been involved in drafting the lga guide and pas 79 he and his fellow authors had thought it appropriate to give a general warning about the dangers of cladding
00:26:19 warning about the dangers of cladding but without any specific reference to acm
00:26:22 acm but still did not consider it was part of the rro and therefore did not refer to it in the section of the lga guide concerned with risk assessment he said that there was nothing and other
00:26:33 he said that there was nothing and other guidance provided to fire risk assessors either sleeping guide guidance note number one and lacquers which would lead to a contrary conclusion so it's noted that even dr lane
00:26:45 so it's noted that even dr lane struggled to reach a conclusion on whether the external wall fell within the scope of the rro and she acknowledged a body of opinion that it did not
00:26:55 did not it submitted the reason she gave us to why it might fall within the rro that it is a collective protect collective protective measure if it abuts an internal compartment or common
00:27:06 abuts an internal compartment or common part does not on analysis apply as the common lobby at grenfell tower was land locked and did not abut the external wall the the submission made that colin todd
00:27:17 the the submission made that colin todd wrongly conflated his and his practice's view of the view of the trade as noted but it submitted the inquiry is entitled to hold that his view is properly represented of the industry because he
00:27:28 represented of the industry because he occupies a senior post within the industry was one of the authors of past 79 and the lj guide colin todd's view was that the rro cut
00:27:39 colin todd's view was that the rro cut in as he said it after the building regulations have been applied and he considered it was reasonable to place waste on the fact that building control both approved or at least did
00:27:50 control both approved or at least did not demur in the initial installation of the cladding and then signed it off as compliant it is also significant that the fire safety act recently amended the rro to
00:28:01 safety act recently amended the rro to say clearly that external walls including windows and doors and multi-occupancy buildings do fall within the scope of the rro so the need for such an amendment is
00:28:12 so the need for such an amendment is strong evidence it's submitted that the external war was not previously within the scope of the rro or at least support for the proposition that it was reasonable not to think it was
00:28:24 the question may rightly be asked whether
00:28:26 whether other responsible persons or their fire risk assessors who had buildings clad in acm addressed this in their fire risk assessment if they did not this tends to suggest
00:28:37 if they did not this tends to suggest that industry practice was not not to include it in those assessments to whether carl stokes should have suggested that the tmo appoint a specialist the tmo invites the inquiry
00:28:49 specialist the tmo invites the inquiry to adopt the view of colin todd that it wouldn't have been appropriate and i quote said that it wouldn't have been appropriate to take a project that has just been completed completed under building regulations
00:29:01 building regulations and pay a rarified specialist to come along
00:29:04 along and drill holes in it and stick a boar scope to see if any cavity barriers were in place
00:29:12 dealing now with the letter from the london fire brigade dated the 6th of april 2017 tall buildings external fire spread on receipt of the letter from rbkc
00:29:23 on receipt of the letter from rbkc janice ray passed it on to carl stokes among others and he confirmed that grenfell towers cladding quotes complied with the requirements of the building regulations
00:29:34 requirements of the building regulations lots of questions asked of ryden's and answers received back from them while with hindsight excuse me while with hindsight the sufficiency of his
00:29:45 with hindsight the sufficiency of his response may be questioned it is submitted that it was a reasonable approach to take following an extensive refurbishment by specialist companies and in the light of the wider view about
00:29:56 and in the light of the wider view about the acceptability of such cladding at the time
00:30:01 the time the tmo submits that it's highly unlikely to think that a unilateral inquiry conducted at that time no matter how intensively it was conducted
00:30:11 conducted might have uncovered the terrible error of cladding grenfell tower in combustible materials without adequate cavity barriers this was a project which had been conducted in plain sight including of
00:30:24 conducted in plain sight including of the lfb during their 72d visits over a period of years and at no party at no point at any party said it was dangerously misguided the fact that so many other buildings
00:30:35 the fact that so many other buildings were and continue to be clad in similarly dangerous materials speaks to the very remote possibility that any one investigation would have exposed the deep-seated and far-ranging
00:30:46 deep-seated and far-ranging misconception that gave rise to the tragedy at grenfell tower it's a massive inquiry but the tmo submits that the more pressing question is not why the 2017 letter was not
00:30:58 is not why the 2017 letter was not responded too differently but why in the light of evidence heard in module 4 about the fire service's wider awareness of the dangers of acm cladding the more urgent alarm was not
00:31:09 cladding the more urgent alarm was not sounded earlier and more widely further the letter sent by the lfb related spandrel panels and not the acm panels installed at grenfell tower
00:31:20 panels installed at grenfell tower colin todd said it was right to make a distinction between them and acm cladding
00:31:26 cladding janice ray's response i can confirm that it is our understanding that we do not have any blocks with cladding of the nature describing the lfb's letter was not incorrect laura johnson of rbkc also understood it
00:31:38 laura johnson of rbkc also understood it was not the same cladding involved in the shepherd's court fire turning now to the tm owes a tmo's approach to fire risk assessments in particular article 9 of the rro
00:31:50 particular article 9 of the rro [Music]
00:31:52 [Music] when the nfb recommended that the tmo engage an external fire risk assessor it immediately did so and sabus was appointed in september 2009 to carry out fire risk assessments
00:32:04 2009 to carry out fire risk assessments on the tmos high-risk housing stock so we appreciate that the inquiry will carefully consider the circumstances in which karl stopes was appointed after salvos
00:32:15 salvos the quality of service he provided to the tmo and the extent to which his performance was reviewed over time and so this is likely to include consideration whether there was any irregularity around his appointment and
00:32:28 irregularity around his appointment and if there was what were its effects in relation to this suggested irregularity submitted the explanation janice ray gave should dispel concern that the process was deliberately
00:32:40 that the process was deliberately manipulated she said the tmo treated all applicants fairly and equally at interview and the interview was attended by an rbkc housing representative and another
00:32:51 housing representative and another professional service colleague regarding the infamous information given to carl stokes the lesser before the interview she said that a lot of that information would have been covered verbally
00:33:02 verbally at the beginning of every interview and certainly salvers another applicant had that information
00:33:10 in general the tmo accepts that also although some concerns were laterally raised about aspects of carl stokes performance and there were certainly some anomalies and vagaries in his
00:33:22 some anomalies and vagaries in his assessments which the inquiry is scrutinized the fact is janice ray was aware of them and the concerns expressed about him but these taken collectively were not of
00:33:33 but these taken collectively were not of a type that justified dispensing with him and his services altogether in any event on the question of his actual and ostensible competence the inquiry cannot overlook it's submitted
00:33:45 inquiry cannot overlook it's submitted colin todd's opinion that carl stokes fire risk assessments were in general terms suitable and sufficient and amongst the quote from colin todd some of the most detailed the many
00:33:56 some of the most detailed the many thousands he had seen colin todd said he did have suitable experience and training to be to be trained properly to be regarded as competent the key qualification he held
00:34:09 competent the key qualification he held was the european diploma from the fpa as well as his long experience as a fire safety officer even dr lane agreed that on paper carl stokes had done the correct courses
00:34:22 stokes had done the correct courses although carl stokes wrongly used post nominals and inquiry will it will assess the circumstances in which he represented himself as having these colin todd thought this did not obviate
00:34:33 colin todd thought this did not obviate the fact that he had the correct academic qualifications and merely amounted to an unnecessary attempt as he put it colin todd was it to big himself up
00:34:44 to big himself up also by the time carl stokes was appointed he had done numerous fire risk assessments on tmo high-risk blocks for salvas so janice ray had first-hand experience of his work
00:34:56 experience of his work salvas had also quality checked his work and all of his risk assessments were provided to the lfb for review colin todd did not agree
00:35:07 colin todd did not agree that a fire risk assessor should be sufficiently qualified and educated to be able to examine the external wall as part of his fire risk assessment
00:35:18 part of his fire risk assessment so the inquiry also explored the issue whether the tmo should have appointed a sole practitioner such as carl stokes it's a matter for the inquiry sir but against the background of poor performance or alleged poor performance
00:35:29 performance or alleged poor performance by so many corporate entities the the simple premise that it was inadvisable to appoint and rely upon a sole practitioner is open to question in any event colin todd said he knew of
00:35:41 in any event colin todd said he knew of many extremely good sole practitioners who do a very good job without anyone reading or peer reviewing their reports
00:35:50 the tmo acknowledges that there came a time in 2015 when the lfb expressed concerns about some of carl stokes works work but against the background of his
00:36:01 work but against the background of his wider performance and considering colin todd's views generally it's submitted that these were not so serious as to have caused the tmo to dispense with his services
00:36:12 services janice ray said she fed these back to him so he was aware of them further as rbkc noted in their written submissions the last risk assessment carried out by carl stokes on grenfell tower in 2016
00:36:25 carl stokes on grenfell tower in 2016 was deemed to be suitable and sufficient by the inspecting fire officer one issue is whether carl stokes ought to have said in ad hoc advice to the tmo
00:36:36 to have said in ad hoc advice to the tmo the cladding combined complied with the requirements of building regulations without having verified it himself dr lame was extremely critical of this and colin todd was questioned on it but
00:36:48 and colin todd was questioned on it but he said that kyle stokes statement was reasonable in the circumstances and any criticism of it would be pedantic
00:36:57 pedantic turning now to the issue of the competent person under article 18 touching on janice ray her experience and qualifications
00:37:09 so contrary sent to some of the submissions made by core participants in written closing submissions on module three
00:37:16 three the tmo maintains the submission that janice ray was a hard-working and conscientious health and safety professional who worked effectively and efficiently despite at times being
00:37:28 efficiently despite at times being overstretched while she accepted she could have done things differently or better of whom can that not be said especially when their conduct is subject to forensic scrutiny
00:37:41 to forensic scrutiny janice ray started working for the tmo in around 1989 and obtained a nebosh diploma which is the globally recognized health and safety qualification she's also a child member of the
00:37:53 she's also a child member of the institution of occupational health and safety
00:37:56 safety and this required her to maintain high levels of continuous professional development which she did she received training on the rro when it was first introduced and attended several courses on it she also attended
00:38:09 several courses on it she also attended two presentations on the lacrimal fire and shirley towers fire in 2013-2014
00:38:17 her assistant health and safety advisor adrian bowman had also been with the tmo for a long period of time and was himself
00:38:24 himself nebosh qualified cyril morris the third member of the team had joined the tmo in 2011 and reported to her
00:38:33 to her she received training on the 2006 sleeping guide and it is submitted and it is submitted was familiar with past 79 to a level appropriate for a competent person
00:38:44 competent person engaging a specialist fire risk assessor she was also familiar with the lachlan's guide she had an overview of bs 9991 and was familiar with the guide fire safety
00:38:55 was familiar with the guide fire safety and purpose built blocks of flats published in 2011. jannis ray was far more familiar with the lga guide published in july 2011 and
00:39:06 the lga guide published in july 2011 and in fact had been consulted on it during its production so the inquiry will note that the lga guide was produced as a specific reaction to the lack of fire as it was
00:39:17 reaction to the lack of fire as it was considered that there was a lack of guidance dealing specifically with fire safety and high-rise residential blocks indeed statements made within the guide itself which were referred to in written
00:39:28 itself which were referred to in written submissions and so which we don't propose to go into in these oral submissions support the proposition that it was to be used in preference to other guides and therefore it was right that janice
00:39:40 and therefore it was right that janice ray paid particular attention to it she was also a member of the london and southeast health and safety group for the public sector which was attended by health and safety housing professionals
00:39:52 health and safety housing professionals from different local authorities at this forum she inquired how others were seeking to comply with legislation and guidance and use this to benchmark tmo's compliance including towards vulnerable
00:40:05 compliance including towards vulnerable residents
00:40:06 residents her conclusion was that the tmo compared well to others and so the inquiries had no evidence to dispute this she also had regular two monthly meetings with the lfb
00:40:18 meetings with the lfb as well as being an attendee at the rbkc maine health and safety committee which met every six weeks and later became the byboro health and safety group in conjunction with
00:40:29 safety group in conjunction with hammersmith and fulham she also had regular meetings with gary mann one of our bkc's corporate health and safety advisors submissions have been made by some core
00:40:40 submissions have been made by some core participants that others in the tmo including barbara matthews and sasha jevons ought to have been trained in fire safety while it's right that the inquiry considers these suggestions the tmo
00:40:51 considers these suggestions the tmo submits that it was not necessary for them to have any specific fire safety qualifications to exercise their managerial role of janice ray
00:41:02 janice ray as to whether janice ray ought to be part of the senior management team robert black from whom you heard said that he did not think it was necessary for her to be part of that team or the executive team
00:41:14 executive team his view his view was that she was influential within the organization from the position she occupied and so i submitted that having her outside the operational contractual side of the organization was logical
00:41:27 of the organization was logical and preserved her independence she was the key report in health and safety meetings chaired by sasha jevons and then barbara matthews both of whom both of whom were members of the
00:41:38 both of whom were members of the executive team and so she could escalate matters to that team through her dealings with them
00:41:46 an issue that was raised was whether janice ray was overstretched and whether she had the resources to carry out her role effectively she agreed that she was spread very thinly to use her words but she and her
00:41:58 thinly to use her words but she and her team and so this was three not as was suggested were adept again to use her words at prioritizing and making things work and fire safety was always top of the pile
00:42:11 was always top of the pile she accepted that resources influenced how quickly some things were done for example she accepted the fire safety strategy took longer to develop than it ought to have done but as she said she chased chivied and
00:42:24 but as she said she chased chivied and escalated matters to the best of her ability
00:42:27 ability she also said that the contracts team had various responsibilities for fire safety matters so compliance was not solely down to her and her team
00:42:38 so when considering whether she was under a source the inquiry should bear in mind it's submitted that these were times of cuts and austerity and the tmo's budget was limited by
00:42:50 and the tmo's budget was limited by government as with any other social housing body at that time robert black indeed said local authority funding was cut from 2009 and when he took over there had been a budget cuts
00:43:02 took over there had been a budget cuts of 500 000 pounds or 2 percent although the cr the tmo is criticizing some courses for not seeking additional funding robert black explained that all
00:43:13 funding robert black explained that all similar bodies were having to adjust to funding cuts and there was no magic pot of money
00:43:19 of money whether a result by the tmo for more money from rbkc would have resulted more money being allocated is essentially speculative but so it's noteworthy that when a request was made for site for finance
00:43:31 request was made for site for finance for a door closer inspection maintenance program
00:43:34 program the response was only partially positive
00:43:38 janus ray was questioned on whether she tried to challenge the lfb in an approach in an approach inappropriate man of forgive me i.e why she did not merely acquiesce in what the lfb was
00:43:49 merely acquiesce in what the lfb was saying the tmo should do one example considered was the challenge the lfb in february 2010 which concerned retrofitting dry rises at gilray house
00:44:01 retrofitting dry rises at gilray house and in four other blocks over 80 meters her explanation for the challenge was that this would cause huge disruption to residents
00:44:08 residents and it's submitted there is some force in this and her challenge was consistent with a public sector professional seeking to avoid disruptive and intrusive works on a residential block
00:44:20 intrusive works on a residential block where possible she said that she made challenges of this type to determine whether the lfb requirements were national and or across london and it's submitted that this was not unreasonable
00:44:33 dealing now with a separate general topic about the failure to escalate concerns expressed over time sir several witnesses including janice ray and robert black were questioned
00:44:44 ray and robert black were questioned extensively on whether the tmo sought deliberately to conceal or downplay important information from both residents and the tmo board
00:44:55 residents and the tmo board has been suggested in some written submissions that if residents have been provided with information about for example
00:45:02 example the fact that studio was inexperienced in cladding high-rise blocks that zinc was to be replaced with acm cladding and that exo's reports were not comprehensive nor updated the fire at
00:45:14 comprehensive nor updated the fire at grenfell tower could have been averted
00:45:20 dealing first with the suggestion with the suggested withholding of information from residents while the tmo accepts that these are important questions to ask it's submitted that it's highly unlikely that
00:45:31 submitted that it's highly unlikely that even if the residents were provided with the information which it is said they were denied this would have averted the tragedy at grenfell tower as has been said before but importantly the causes
00:45:43 said before but importantly the causes of the tragedy at grenfell tower deep seated and far-ranging and so we would submit that it's unrealistic to think that the actions of one group even the residents of the tower would
00:45:54 even the residents of the tower would have been adequate to unpick them and avert the
00:45:58 avert the fire concerning the allegation that any tmo employee acted in bad faith towards residents this is not accepted it's ultimately a matter for the inquiry to judge but it's submitted that tmo
00:46:09 judge but it's submitted that tmo employees were all well intentioned and conscientious individuals who had made the vocational choice to work in social housing and it submitted that it's highly improbable that they would ever have
00:46:21 improbable that they would ever have deliberately and purposefully sought to deceive or disadvantage the residents whom they served now dealing with the question of whether the tmo ever concealed the fact that it
00:46:32 the tmo ever concealed the fact that it had been issued with notices of deficiency or downplayed or sanitized other serious concerns expressed about it
00:46:40 it or carl stokes it's accepted that before the death tower fire at the end of 2015 the tmo did not have a bespoke system for registering and escalating nods and it
00:46:53 registering and escalating nods and it is accepted that this may have led to them not being dealt with any in a sufficiently formal way that there was no such system is likely connected with the fact that as janice
00:47:04 connected with the fact that as janice ray said
00:47:05 ray said nods were non-statutory notices and were considered to be the lowest level of enforcement by the lfb non-compliance with nods did not result in formal action but could cause them to
00:47:16 in formal action but could cause them to be escalated to an enforcement notice janice ray said that priya dare the tmo did not receive a lot of nods and those it did receive and often only contain
00:47:28 it did receive and often only contain two or three recommendations or were easily resolved while it seems right and it is accepted so that some notices were not brought to the direct attention of the tmo board
00:47:39 the direct attention of the tmo board the inquiry is invited to accept janice ray's evidence that on receipt of a notice of deficiency she would provide an update of the next available opportunity to either the tmo tmo's operations committee the health
00:47:52 tmo's operations committee the health and safety committee and the executive team
00:47:55 team and she would record it in the tmo's annual health and safety reports such reporting is we submit not consistent with the suggestion that they were deliberately underplayed or
00:48:06 were deliberately underplayed or concealed from councillors or the tmo board
00:48:11 so also once while it's accepted that the receipt of a deficiency notice should have been minuted at for example board meetings the mere fact that they were not minuted does not mean to say
00:48:22 were not minuted does not mean to say that they were not discussed there or elsewhere
00:48:26 elsewhere janice ray said that as time progressed the tmo became more overt to use her word about publicizing them but generally the tmo would be having discussions with the lfb
00:48:37 discussions with the lfb about how best to address the issues raised
00:48:42 so how they were escalated is certainly an important matter to consider but it's submitted that it's more important to consider whether the matters raised in the notices themselves were dealt with properly and it
00:48:54 were dealt with properly and it submitted the evidence shows that they generally were certainly no more serious enforcement action was taken against the tmo for failing to deal with matters in an in a notice of deficiency
00:49:07 notice of deficiency following the dare fire the format and structure of fire safety updates the tmo board changed and the tmo began listing all nods that had been received the board was therefore told about the
00:49:19 board was therefore told about the receipt of nods in november 2016 and march 2017 and a summary of the the enforcement notice for dare tower was sent by email to the board on the 12th of january 2016
00:49:33 to the board on the 12th of january 2016 including that a similar enforcement notice was also expected for hazelwood tower
00:49:40 in relation to the suggestion that the force of the matt hodgson report was hidden from the board so whatever conclusions the inquiry reaches about the way in which the report was escalated it cannot be said that it was
00:49:52 escalated it cannot be said that it was ignored
00:49:53 ignored tmo did indeed use his report to change or amend some of its processes including the provision of health and safety trained to senior members of tmo staff including sasha jevons
00:50:04 staff including sasha jevons and the formation of the operational health and safety committee commenced regarding the suggestion that the criticisms of carl stokes were kept from the board
00:50:15 the board the first time that substantive criticisms were raised by the lfb was after the adair tower fire by this time he had been imposed for several years and had developed a good reputation
00:50:27 reputation his risk assessments had been provided to the lfb across time without any substantive criticism it's also significant that his last risk assessment before the fire and after the concerns expressed by the
00:50:38 and after the concerns expressed by the lfb in 2015 was considered by the lfb fines fire safety inspecting officer michelle michelle mchugh and she deemed it to be suitable and
00:50:49 and she deemed it to be suitable and sufficient janice ray said she investigated the criticisms that were made to her and said that as there was no sustained history of concerns being flagged she was satisfied about carl stokes over
00:51:02 was satisfied about carl stokes over overall competence barbara matthews pointed out in evidence that tmo had begun a re-procurement process in relation to its appointed fire risk assessor
00:51:13 fire risk assessor as a natural consequence of the time that he had remained imposed and so so therefore it cannot be said that tmo was in some way hanging on to carl stopes come what may
00:51:24 hanging on to carl stopes come what may and in the teeth of adverse comment again while the tmo accepts that it's right to consider consider whether legitimate concerns were properly escalated
00:51:35 escalated inquiry may consider the more important issues whether carl stokes was competent and whether the tmo had a basis for thinking this on these topics it's submitted the inquiry cannot properly overlook the
00:51:47 inquiry cannot properly overlook the evidence of its own specialist in fire risk assessment colin todd who commended much of carl stokes performance
00:51:58 dealing now with the fra action backlog a significant topic covered in module three was the nature of the backlog of the fire risk assessment actions and how it was dealt with by the tmo
00:52:11 and how it was dealt with by the tmo when considering the backlog of fra actions it's submitted the inquiry should at least attempt to benchmark the tmo situation with that of other local authorities
00:52:22 of other local authorities and or other social housing providers at the relevant time in this way it will be able to verify whether what was said by tmo witnesses that they had benchmarked tmo's performance across the sector and found
00:52:35 performance across the sector and found it was in a stronger position than many others was correct in general terms the tmo submits that it always sought to keep abreast of the problem of outstanding fra actions and
00:52:47 problem of outstanding fra actions and always made constructive efforts to drive the numbers down while the level of outstanding action certainly ebbed and flowed the tmo was always making robust efforts to reduce
00:52:58 always making robust efforts to reduce the number several issues led to the high initial number of outstanding actions as well as the number going forward a high number of outstanding actions had arisen prior
00:53:09 of outstanding actions had arisen prior to 2012
00:53:11 to 2012 as the tmo's responsive repairs contract with morrisons was failing sasha jevens said that there were always problems with the contractor who knew it was coming to the end of its tenure
00:53:22 was coming to the end of its tenure the backlog worsened through difficulties encountered with rge the contractor responsible for the maintenance of fire safety equipment across the housing stock however when the tmo received the
00:53:34 however when the tmo received the limited assurance rating in the rbkc health and safety audit in 2013 it did take positive steps by changing its structure and much of its personnel
00:53:46 its structure and much of its personnel and reprocure the contract with rge which also included lengthy adjudication process
00:53:53 process and brought in an interim contractor chub
00:53:57 chub as a direct result of the limited assurance order the tma brought him matt hodgson to conduct his review and one of the consequences of this was the initiation as i said of the operational health and safety committee
00:54:09 operational health and safety committee which was chaired by sasha jevons the committee started to meet in september 2013 and around this time the tmo was in the process of introducing the w-2 workflow
00:54:21 process of introducing the w-2 workflow to improve the monitoring and completion of fra actions janice ray sent the relevant teams a spreadsheet of actions downloaded from w-2 on a bi-monthly basis and would also
00:54:33 w-2 on a bi-monthly basis and would also report on the status of fre actions to the health and safety committees which reported into the executive executive team
00:54:41 team and in the annual health and safety report and within the health and safety section of the ceo's report to the tmo board
00:54:50 the tmo accepts that the metric adopted in a number of these forms was completing fra actions completing outstanding free actions rather than consistently highlighting which action
00:55:01 consistently highlighting which action items were high low or medium risk and or the age profile of the action however as janice ray said this information was available
00:55:11 available and it was disseminated along with the stasis of actions on a regular basis as to the criticism that the tma felt to take a holistic view of the state of risk at grenfell tower in light of the
00:55:23 risk at grenfell tower in light of the fact that so many actions remained remained unremediated the tmo points to colin todd's evidence on the topic that the risk associate associated with an uncompleted action did not change
00:55:35 uncompleted action did not change as a function of how long it remained outstanding although it's accepted that he said that this would give concern or should give concern about the wider management system which
00:55:46 about the wider management system which the tmo acknowledges following the appointment of barbara matthews in june 2015 the two health and safety committees were brought under one umbrella and under her leadership there
00:55:58 umbrella and under her leadership there was a new focus one of the initiatives was to have janus ray provide a further breakdown of outstanding action so the committee could see what was required to to clear the back clock
00:56:11 following this janice ray included further information in relation to risk level high medium low for example and lastly the age profile nought to three months six to 12 months etc which
00:56:24 three months six to 12 months etc which provided a more accurate age and risk profile of out of outstanding actions although the backlog was not cleared steady progress was made from late 2015
00:56:35 steady progress was made from late 2015 and by april 2016 there was a large drop in the number of outstanding actions and so as the inquiry knows significantly in 2016 the tmo received a substantial assurance rating
00:56:47 substantial assurance rating in an rbkc health and safety audit which was produced by external auditors
00:56:56 notwithstanding the efforts made in january 2017 barbara matthews expressed concern that there was still a volume of actions which had been outstanding for over 12 months requested
00:57:07 outstanding for over 12 months requested that teams present an action plan at the next meeting it seems likely that the slowing of improvement was because there had been another handover between two contractors rge to allied protection
00:57:19 rge to allied protection which created as peter madison put a turbulence in terms of performance during the transition period at the march 2017 health and safety committee was noted that there has been
00:57:31 committee was noted that there has been increased focus on clearing the backlog as well as keeping current records up to date although barbara matthews again reiterated the need for all to continue and i quote prioritizing completing these and to
00:57:43 prioritizing completing these and to prevent further actions falling into the 12 plus months category although it's accepted that there were many actions which fell into the 12 plus months category at this time
00:57:55 months category at this time the enquiries invited not merely to view the question of outstanding actions as a numbers game but also to look at what their risk ratings were it should also separately consider the question whether
00:58:07 separately consider the question whether and to what extent any any outstanding actions were implicated in the causes of the fire or influenced the severity of it once it had started
00:58:18 it once it had started it was suggested that tmo the tmo in particular peter madison sought inappropriately to reprioritize actions to reduce the backlog the inquiry will view this evidence as
00:58:29 the inquiry will view this evidence as it does but it's submitted that peter madison's conduct was consistent with a practical approach towards reducing a stubborn backlog as he put it as quickly and as effectively
00:58:41 he put it as quickly and as effectively as possible in relation to interim measures the tmos fire safety strategy dated november 2013 required that when a high priority action could not be progressed as
00:58:53 action could not be progressed as urgently as possible because of for instance resources or procurement issues then interim measures would be implemented janice ray said she asked the contracts
00:59:04 janice ray said she asked the contracts team to put measures in place but in answer to your question so the chairman's questions she said she would not necessarily have made a document documentary record of them but would have discussed matters
00:59:16 them but would have discussed matters with carl stopes she said and i quote i would have told him by email or on the telephone because we would have probably started off having discussions about what potential interim measures
00:59:28 about what potential interim measures might be adequate so now dealing with the topic of recording prescribed information in particular any group of persons identified by the assessments as being especially at risk
00:59:40 especially at risk in relation to articles 9 brackets 6 and 7 of the rro articles 9 6 and 9 7 of the rro required the responsible person
00:59:53 the responsible person to identify and then record information regarding persons especially at risk particularly disabled residents colin todd agreed that article 97b did
01:00:04 colin todd agreed that article 97b did say that information should be included in the fire risk assessment about any group persons identified by it as being especially at risk but said that this was not normally acted on by
01:00:16 that this was not normally acted on by the fire risk fire risk assessment trade even before the publication of the 2011 lga guide because of practical difficulties in obtaining and
01:00:27 difficulties in obtaining and maintaining up-to-date information therefore he said he would not normally have expected to see a detailed person-by-person breakdown in a fire risk assessment but sir and and the
01:00:39 risk assessment but sir and and the tiemou conceit he did say that he would have expected carl stokes to ask whether the tmo had any arrangements in place for giving assistance to disabled people
01:00:49 people and whether it had some high-level generic
01:00:51 generic information while dr lane took a different view as sir she often did as compared with colin todd it's submitted that his view is likely to be
01:01:03 submitted that his view is likely to be more representative the practice of the fire risk assessment trade at the time and therefore a better yardstick for measuring the tmo's compliance dealing now with peeps
01:01:15 dealing now with peeps the tmo's general approach towards peeps was captured in janus ray's evidence she said that peeps for residents in general needs housing blocks unlike in sheltered housing
01:01:26 sheltered housing were not carried out because there was no because there were no staff present on site all the time and so no one to assist in the evacuation of disabled persons in an
01:01:37 evacuation of disabled persons in an emergency
01:01:39 emergency in adopting this approach the tmo was actually in a way consistent with the guidance provided in the 2011 lga guide which said and i quote sir it's usually unrealistic to have in place special
01:01:51 unrealistic to have in place special arrangements such as personal emergency evacuation plans
01:01:56 plans as they rely on the presence of staff or others available to assist the persons to escape in a fire while the inquiry has not heard direct evidence on the point it's submitted the
01:02:07 evidence on the point it's submitted the tmo's approach was likely to be consistent with most other social housing profile providers in fact sir teresa brown from whom you've heard would work for the london
01:02:18 you've heard would work for the london borough of hemispheres and fulham said she could not recall having done any peeps there even after the production of the lga guide although other guidance said different things about peeps and how the rro
01:02:31 things about peeps and how the rro should be interpreted submitted the tmo is justified and following the lga guide in preference to other guidance dr lane's suggestion that a range of guidance should have been consulted in
01:02:43 guidance should have been consulted in our submission potentially amounted to the type of cherry picking that rebecca burton from the lfb said was undesirable
01:02:53 colin todd's viewers that peeps were not reasonably practicable in general needs housing blocks and he stood by the statement in the lga guide which he noted had been read and approved by
01:03:05 noted had been read and approved by government lawyers during the consultation process excuse me part of the rationale for the statement was again that there were significant problems ensuring that
01:03:17 significant problems ensuring that details in a peep remain current and the dangers of inaccurate information being passed on to the fire and rescue service might be more harmful than no information at all as the fire
01:03:28 than no information at all as the fire service may spend valuable time searching for those about whom there was inaccurate information in evidence colin todd gave some stark examples of the type of problems that
01:03:39 examples of the type of problems that may arise in practice rebecca burson of the lfb also agreed that it's very difficult to have peeps in place for general needs high-rise buildings
01:03:50 buildings so the tml accepts that dr lane said this view is not consistent with the equality act 2010 and while of course the tmo acknowledges her view it asks the rhetorical question what compliant
01:04:02 the rhetorical question what compliant solution was available so a matter for the inquiry but it may be the key to the problem lay in the initial allocation decision which was outside of the tmo's hands
01:04:14 which was outside of the tmo's hands the tmo accepts that in some early con correspondence such as robert black's letters in 2010 and in the health and safety report to the board it was suggested that peeps
01:04:26 the board it was suggested that peeps were being prepared when that never happened
01:04:30 happened it's certainly right that the reference the preparation of peeps particularly in the report should have been amended but so the timo's final approach was dictated by what could practically be achieved
01:04:40 achieved and the provisions of the lga guide
01:04:45 but this is a difficult and intractable issue is illustrated by the fact that even today the top the topic generates many differing views and is still being consulted on by the government further
01:04:56 consulted on by the government further to your
01:04:57 to your recommendation sir in your phase one report
01:05:02 report turning now to the question of emergency roots and exits article 14 compliance with
01:05:08 with the inquiry explored the issue of how the tmo should have been applying articles 14 and 15 of the rro particularly with colin todd he said that when applying article 14 2b
01:05:20 he said that when applying article 14 2b the interpretation of the fire risk assessment trade was the responsible person could rely on the fire and rescue services to evacuate disabled residents from the building
01:05:31 building if residents were not able to use other designated routes such as the protected stair
01:05:36 stair this was consistent with janice ray's view that it was for the lfb to use her words to call the shots on any necessary evacuation colin todd said the state put meant the
01:05:47 colin todd said the state put meant the responsible person didn't have to consider evacuating disabled people and as far as able-bodied residents were concerned his view was the tmo discharge its responsibilities under the article
01:05:59 its responsibilities under the article by the provision of for example the protected
01:06:03 protected used as a place of refuge until the fire and rescue service could assist the person
01:06:08 person he said this was because in the event of a fire the building would be under the control of the frs fire and rescue service so while he recognized rightly submitted these views
01:06:21 recognized rightly submitted these views may seem harsh towards the disabled and vulnerable his interpretation was influenced by the fact that it that it is and was vanishingly rare
01:06:32 vanishingly rare for people to die outside of their own flat
01:06:35 flat in fires and purpose built blocks of flats
01:06:38 flats and for this reason planning for wider evacuation was negligible as he put it as compared to ensuring residents were safe in their own flats his view was the safety of disabled
01:06:49 his view was the safety of disabled people within their flats was not a matter for legislation including the rro but it was for multi-agency cooperation to identify vulnerable people and ensure
01:07:00 to identify vulnerable people and ensure measures were taken to ensure they did not succumb because of a fire in their own flat this is what he referred to as person-centered fire risk assessment or
01:07:11 person-centered fire risk assessment or pcfra
01:07:13 pcfra and so in this context teresa brown said the tmo was concerned to identify those who were vulnerable and to refer them to neighbourhood teams when they needed additional support
01:07:25 when they needed additional support janice ray said consideration was given to the safety of vulnerable individuals with their within their own homes citing how the tmo focused on hoarders and those who sense a vulnerability led
01:07:37 and those who sense a vulnerability led them to put protective metal gates on their front doors which might hamper the lfb in their efforts to rescue them so as the inquiry knows around and
01:07:48 so as the inquiry knows around and before 2017 the tmo was making efforts to improve the data it held on vulnerable residents in its electronic systems although it's accepted that the list produced on the
01:08:00 accepted that the list produced on the night of the fire was incomplete so rightly colin todd was pressed on how his view could be squared with the contents of bs 9991
01:08:11 contents of bs 9991 which suggested something different he said that bs 9991 was primarily concerned with designing and managing new buildings and was an alternative to adb
01:08:22 adb and whereas past 79 referred to the need for peeps it too concentrated on non-residential buildings recognizing there would not be staff available to assist in evacuation of a disabled
01:08:34 assist in evacuation of a disabled resident in the event of a fire as there was in business premises dr lane said bs 991 9991 and the lga guys should be read together but she
01:08:45 guys should be read together but she could not reconcile the two she said she was not aware of any parts of past 79 not applicable to residential buildings but it submitted that colin todd's viewers to be preferred on
01:08:57 todd's viewers to be preferred on account
01:08:58 account amongst other things with a limited reference to residential blocks of flats in that document
01:09:06 the inquiry may conclude in relation to the application of guidance dr lane said that what was key was the responsible person needed to ensure the internal compartmentation an external wall remained as she put it
01:09:18 an external wall remained as she put it reliable so that they and again to use her word set so that they are not entering into the deeply complex territory
01:09:26 territory of needing to plan for the total evacuation of a high-rise residential building
01:09:31 building realistically we submit she agreed with your suggestion sir that in most cases the risk of a catastrophic failure of a building of a kind that would require a total evacuation
01:09:42 total evacuation is too small to justify taking precautions against it now to the issue of emergency emergency plans procedures for serious and imminent danger and for danger areas
01:09:54 imminent danger and for danger areas article 15 of the rro the question of emergency plans and the sufficiency of the tmos emergency plan also needs to be considered in the light of the lga guide which says in paragraph
01:10:07 of the lga guide which says in paragraph 79.1
01:10:08 79.1 that rarely and purpose build blocks of flats will it be necessary to have a more elaborate emergency plan than a simple fire action notice nor will it be universally necessary to
01:10:19 nor will it be universally necessary to displace to display such notices colin todd said the majority view was that in a block of flats the article 15 duty was satisfied by having a stay put strategy
01:10:30 strategy you recognize that to call this an evacuation strategy was probably a misnomer because it was essentially a non-evacuation strategy he did not say that a staple strategy
01:10:41 he did not say that a staple strategy without moore provided an answer answer to article 15 however rather he stated the duty holder might be expected to tell residents that they should leave their flat of a fire started in it
01:10:52 started in it and leave if instructed by the fire and rescue service and so as the inquiry knows by the time of the fire fire action notices have been installed in the communal areas at grenfell tower
01:11:03 the communal areas at grenfell tower and these red and you've seen the notices if you are safely within your flat and there is a fire elsewhere in the block you should initially be safe to stay in your flat keeping the doors and windows closed on
01:11:15 keeping the doors and windows closed on arrival the fire brigade will make an assessment and will assist with evacuation if required while the sleeping guide said it was necessary to have an emergency plan to
01:11:26 necessary to have an emergency plan to deal with any fire situation it said that in simple premises the emergency plan may be no more than a notice but should be more detailed in multi-occupancy and complex
01:11:38 multi-occupancy and complex premises colin todd said grandfather tower was not a complex premises rebecca berson also considered grenfell tower to be simple premises as it only had a single stare
01:11:50 single stare so moving on now to discrete aspects of topic three of um active and passive fire safety systems at grenfell tower and dealing with the flat front doors
01:12:01 and dealing with the flat front doors and door closers including the initial procurement of doors and their installation
01:12:09 so the tmo recognizes that out of the many topics considered module 3 one likely to give the inquiry particular concern is the topic of flat front doors and
01:12:21 is the topic of flat front doors and door closers especially in the light of the bre findings it has been it has been the subject of intensive and often critical comment in the written submissions of many of the core
01:12:33 written submissions of many of the core participants inquiry heard detailed evidence about the circumstances which the tmo embarked on a door replacement program the tmo liaised with the london housing
01:12:44 the tmo liaised with the london housing consortium on the scope of the flat door replacement program and the lhc provided access to an approved shortlist of companies in accordance with a framework agreement one of the companies on the lh
01:12:57 agreement one of the companies on the lh lhc's
01:12:59 lhc's pre-approved shortlist was mance master door
01:13:03 door it seems that although originally indicated the requirement for smoke seals was missing from the final specifications set out in tender documents supplied to mance mastador
01:13:14 documents supplied to mance mastador mance master ceased trading in 2014 and no witness then employed by it gave evidence of the inquiry so the tier the timo submits that the inquiry should view with caution what is
01:13:27 inquiry should view with caution what is said in the statements made by mance master employees and despite what some of those statements say there is a strong argument that mance was contracted
01:13:38 contracted by the tmo to provide fd30s stores and that is what they purported to supply not least because it was known the doors were to be flat front doors and it was
01:13:49 were to be flat front doors and it was part of the contract that they comply with regulatory requirements and so it's a massively inquiry but it's noted that both our bkc and bsr team one agree that this is what was contracted
01:14:01 agree that this is what was contracted for
01:14:03 for so whether fd30s doors were supplied needs to be viewed in the light of the bre report which said in respect of all flat front doors the iron mongerie and the presence of
01:14:15 the iron mongerie and the presence of intumescent strips and cold smoke seals were generally consistent with those of a fire door however no labels tags or other markings were found to indicate the door was a
01:14:26 were found to indicate the door was a fire door so it should also it should also be kept in mind that carl stokes gave the tmo clear written advice that the doors were ft-30s although he
01:14:37 that the doors were ft-30s although he failed to insist on test certificates being provided colin todd when asked about this said that it was reasonable for car stoves to come to that conclusion in light of all the evidence presented
01:14:48 in light of all the evidence presented to him
01:14:50 to him alex foman of lhc attended the pilot installation and thereafter checked 10 of the doors installed for quality of insulation in his statement he said that he would do a visual inspection of the
01:15:02 do a visual inspection of the intumescent strips for their presence
01:15:07 the evidence about the door's inability to resist fire for 30 minutes is deeply troubling
01:15:13 troubling and further investigation show the non-compliance between what mance tested and supply was on a nationwide scale whatever conclusion the inquiry reaches reaches about the smoke seal element of
01:15:25 reaches about the smoke seal element of the doors it is submitted the tmo cannot rightly be criticized for the fact that the doors were not able to withstand fire for 30 minutes
01:15:36 fire for 30 minutes turning now to the question of maintenance and installation a maintenance and inspection following installation so it's also recognized that tma was on notice that some residents were disconnecting door closers
01:15:50 disconnecting door closers and there is evidence that one of the estate service assistant seamus dunlee disconnected some janice ray became aware of this and told siobhan rumble from whom you heard in
01:16:01 siobhan rumble from whom you heard in evidence to tell him sheamus don lee that he should desist and the latter confirmed in an email that she had done this the tmo acknowledges that the lga lga
01:16:13 the tmo acknowledges that the lga lga guide particularly the bullet points under 82.3 suggested that six monthly inspections should be carried out to identify potential defects and make sure doors remain in good condition
01:16:25 remain in good condition the tml also acknowledges the evidence of andy jack from the lfb about a meeting in 2012 where he says monitoring and maintenance of door closes was discussed
01:16:36 of door closes was discussed janice ray said she did not well recall the meeting with him or any suggested periodicity for checks janice ray accepted an evidence there was not an holistic program for
01:16:47 was not an holistic program for inspection of maintenance but the tmo had the intention to check door closers including when flats became void and when the utility company mainly the gas
01:16:58 when the utility company mainly the gas company gained compulsory entry however as regards the latter check she said the utility company had refused to consent to carry out an inspection on their visit and so it's to be noted that these
01:17:10 and so it's to be noted that these checks were checks of the type that were discussed apparently at the meeting with andy jack in 2012. janice ray said she was not aware of anyone who had a six monthly inspection
01:17:21 anyone who had a six monthly inspection program in place and all so far as she was concerned was struggling with the issue after the adair tower fire it became clear that there had been a genuine
01:17:32 clear that there had been a genuine misunderstanding between the tmo and the lfb
01:17:35 lfb about what the latter required of the tmo
01:17:38 tmo in terms of inspection and maintenance itself of
01:17:42 itself of self-closers janice ray said that she had believed the tmo was supportive of the tmo that the fb was supportive of the tmo's approach
01:17:53 approach when considering how this confusion arose the inquiry may note that notwithstanding the meeting with andy jack in 2012 the tmo had provided many fire risk assessments outlining its current
01:18:04 assessments outlining its current practice on door closers to the lfb over the years and had not been challenged on the approach also in december 2013 janice ray emailed
01:18:15 also in december 2013 janice ray emailed the lfb setting out what was its approach to door closers and never received a response to less one that demurred
01:18:24 in fact even at the meeting between rebecca and janice wren in january 2016 where where the lfb made it plain that the tmo's approach hitherto was not adequate
01:18:34 adequate rebecca burton had said that checks could be done yearly not six monthly as the lga guide suggested
01:18:41 suggested that rebecca burton was advising differently to the lga guide is indicative of the problematic nature of the exercise and so it's also relevant that carl stokes never told the tmo that the
01:18:53 stokes never told the tmo that the guidance suggested a six monthly check when it's submitted he reasonably ought to have done the discussions with the lfb in january of 2016 led to janus ray acknowledging
01:19:05 of 2016 led to janus ray acknowledging in the in the september 2016 paper for discussion that the lfb was advising that the rro requires regular inspection stroke maintenance of self-closures
01:19:16 maintenance of self-closures and landlords must not rely exclusively on void checks to undertake these inspections it's accepted that this occurred some nine months after the meeting with rebecca burst in january 16 as was
01:19:28 rebecca burst in january 16 as was explored in evidence and the inquiry will no doubt consider janice ray's evidence that she was occupied with addressing the matters raised in the enforcement notice it is not accepted as has been suggested
01:19:40 it is not accepted as has been suggested in some written submissions that the tmo was instead in some way engage in an exercise of trying to prove that it was not necessary to have an inspection regime rather this was a situation where the
01:19:52 rather this was a situation where the tmo being aware that its previous regime was deemed was now deemed to be unacceptable was struggling to develop a solution to a difficult problem evidence of the fact that tmo was
01:20:04 evidence of the fact that tmo was seeking to find a workable solution as to be found in the paper for discussion dated the first of march 2017 where it was recorded that the team and i quote sir the tmo has contacted a
01:20:16 i quote sir the tmo has contacted a number of similar organizations seeking information on their policy with regard to self-closing devices all respondents to date include city west harangay nottinghall housing etc
01:20:28 west harangay nottinghall housing etc have confirmed that their policy is to ensure that all flat doors are fitted with self-closers however
01:20:35 however approaches to inspection maintenance of these devices are much less clear and that's the full quota or part of the quote
01:20:42 quote dennis ray said that communications of the london and southeast housing fire safety group revealed that while participants said they were regularly inspecting door closers on closer analysis was this was only when
01:20:54 analysis was this was only when properties became void and there were major works from her recollection there were no dedicated inspection regimes of the kind that the tmo was trying to set up
01:21:06 up as the inquiry knows once attention was drawn to problems with self-closers the tmo set about implementing a program for flat door and self-closure inspection
01:21:17 flat door and self-closure inspection maintenance which it which is expected to be completed within three years it took its proposal to rbkc as it involved involved a large separate capital expense and rbk sees that the
01:21:30 capital expense and rbk sees that the program should be spread over five five years and not three years and also refuse funding for the inspection regime
01:21:39 the tmo notes what's been said in some of the core participants closing submissions on the question of whether the tmo should have placed greater pressure on rbkc to complete the program within three years but submits that this
01:21:51 within three years but submits that this is an unreasonable criticism of it it should be remembered that the tmo did not often come to our bkc for large capital sums and rbkc understood or should have
01:22:03 and rbkc understood or should have understood that the requests related to an important issue of fire safety in blocks for which it was landlord if which is not accepted the tier the tmo is not sufficiently insistent
01:22:16 tmo is not sufficiently insistent rbkc had its own extensive health and safety team and could easily itself have opened up a line of dialogue with the lfb
01:22:26 so dealing with some discrete matters regarding whether all the matters in the november notice of deficiency were closed out and in particular flat 44
01:22:38 closed out and in particular flat 44 in evidence it was put to janice ray apparently based on the bre schedule it was a non-functioning door closer and while it's right that the schedule said this
01:22:48 said this the full report said and i quote so the front door was destroyed however the metal frame was still in place there was a hole concealed in in leaf door closer and the closer was found in
01:23:00 door closer and the closer was found in the debris close to the door threshold three barrel hinges remained attached to a frame and there was also a metal closing chain present and therefore the picture may not be so
01:23:12 and therefore the picture may not be so clear as was put to janice ray in evidence
01:23:16 evidence also the statement of the resident of flat 44 turafat yulma girma who lived there with her husband and son says she left the flat twice and on the second occasion she locked
01:23:28 and on the second occasion she locked the door behind her and ran to the stairwell with her husband regards other checks on flat front doors janice ray said carl stokes was also
01:23:39 janice ray said carl stokes was also inspecting a percentage of door closers as part of his fire risk assessments including some from inside where he could when he could gain access colin todd said the way that carl stokes
01:23:51 colin todd said the way that carl stokes approached checking front doors represented custom practice for fire risk assessors at the time and as to whether he should have recorded which doors had been inspected as part of the sample he said he would
01:24:04 as part of the sample he said he would do so but not all fire risk assessors would
01:24:08 would matthew ramsey from the lfb said he could not give a figure for how many doors he would knock on or what was an acceptable sample he said his concern would be in relation
01:24:19 he said his concern would be in relation to the condition of the doors that he did find
01:24:22 did find he said if carl stokes knocked on five doors and managed to get five open and all was self-closing he would be reasonably happy and so this approach this approach is broadly in line with what carl stokes
01:24:34 broadly in line with what carl stokes described himself as having done lastly on this topic janice ray said she also expected tenants to let the tmo know
01:24:43 know if there was any problem with their doors specifically section 5.3.1 of the tenancy agreement required the tenant will report all repairs and defects in the premises the landlord or its agent immediately
01:24:56 landlord or its agent immediately so this is not to shift responsibility back on to the residents but also to acknowledge that residents could themselves request such repairs so now turning um i hope briefly to two
01:25:08 so now turning um i hope briefly to two last topics which is first of the lifts at grenfell tower and then the gas riser replacement
01:25:16 the lifts at grenfell tower were originally installed in 1971 and refurbished in 2002 to 2006. minor works were also carried out to the list during the refurbishment project in
01:25:27 list during the refurbishment project in 2012 2016. mr halkins is unable to say whether the original lifts complied with the standards applicable in 1971 in every respect but can say that the fireman's
01:25:39 respect but can say that the fireman's control switch did
01:25:43 the evidence in module three touched on the question whether the work in project one was sufficiently extensive to require the lifts to be upgraded to modern firefighting standards many who
01:25:54 modern firefighting standards many who gave evidence did not think that the upgrade was extensive enough to require them to be upgraded to those standards and so whatever conclusions the inquiry reaches on this point it should be noted the tmo is not advised
01:26:07 the tmo is not advised by its specialist lift consultants butler and young that they should be so upgraded even though butler and young had been asked to advise on the topic and so it's right to say that mr halkin said they should have advised on this
01:26:20 said they should have advised on this tmo acknowledges that butler and young witnesses said that dave steppel had given them contra instructions but so for the reasons given in the written submissions which i'm not going to go into now this must be doubtful
01:26:34 it's also noteworthy that prior to the commencement of project 2 cal ford cedar construction consultants also inspect and reported on the lifts and stated the lifts comply with the current british
01:26:45 lifts comply with the current british standards and health and safety required and health and safety requirements applicable at the time of installation straight refurbishment regarding project two an issue is whether a trap door should have been
01:26:57 whether a trap door should have been installed
01:26:58 installed but this should be viewed against the backdrop of the industry concern particularly in social housing the track doors posed a security risk moreover even if one had been installed it would
01:27:10 even if one had been installed it would be unlikely to have afforded firefighters additional protection on the night of the fire as a trapdoor is generally too small for adult persons to climb through and is used primarily to communicate
01:27:21 and is used primarily to communicate with those trapped inside a lift from the outside regarding the important topic of fire keys the tmo specified a drop key in its project brief as drop keys were
01:27:33 in its project brief as drop keys were used across the tmos property portfolio which included a route which included around 170 lifts the lfb was aware that the fire control switch at grenfell tower was operated by
01:27:44 switch at grenfell tower was operated by a drop key and it tested the fire control switch using a drop key so there was also wider concern as to which key was specified by the tmo
01:27:55 which key was specified by the tmo in social housing that euro keys and alternative were widely available and could be used by unauthorized persons during project two the fire control switch was relocated from the ground
01:28:07 switch was relocated from the ground floor to the walkway and although it was disconnected the tmo acknowledges the possibility that this could have caused confusion
01:28:14 confusion although both mr howkins and dr lane agree that there is no evidence it did so
01:28:19 so on the night of the fire mr hauken said the lifts appear to be maintained to an appropriate standard and generally in compliance with the relevant standards and industry practice
01:28:30 relevant standards and industry practice and i quote that sir he said that best practice was to test the lift weekly but this was not what the prevailing standards required and in any event mr todd agreed disagreed
01:28:41 any event mr todd agreed disagreed forgive me with mr hauken stating that weekly testing was unduly onerous and to quote
01:28:47 quote putting more wear and tear on the switch and a more pragmatic period for testing would be one per month as was the case at grenfell tower so notably past 79
01:28:58 at grenfell tower so notably past 79 2020
01:28:59 2020 has now changed to to ch has changed the monthly testing to reflect wider industry opinion carl stokes did not recommend in his fire risk assessment the tmo should
01:29:11 fire risk assessment the tmo should undertake weekly testing of the fire control switch as he did not believe it was necessary if monthly checks were being conducted by a maintenance contractor peters was the tmo's pointed lift
01:29:25 peters was the tmo's pointed lift maintenance contractor from 2014 until the night of the fire and carried out planned prevent preventative maintenance including testing the fire control switch on a monthly basis
01:29:36 monthly basis mark wallace of peters who gave evidence live before the inquiry tested the the fire control switch in both april and may 17
01:29:45 may 17 saying he checked and quotes again that the fire switch was in good and proper working order by inserting what is known as an express drop release key into the switch activating the system
01:29:57 activating the system and checking the lifts would immediately move to the bottom floor mr halkins believed that the testing conducted by mr wallace was sufficient and the correct operation of the switch on 9th of may suggests that it was fully
01:30:10 on 9th of may suggests that it was fully operational at that point in time if the correct key was used was used the fire control switch was also tested by bureau veritas in april 17 and no faults were detected
01:30:24 17 and no faults were detected so while acknowledging dr lane's conclusions that there are no records confirming the fire lifts which at grenfell tower was properly maintained nor are their records proving its performance was adequate the tmo submits
01:30:35 performance was adequate the tmo submits the inquiry may rely on the evidence of mr howkins supported by evidence from from peter's contractors alongside other documentary evidence
01:30:47 the lfb has suggested that the fire control switch did not work because of debris found on examination following the fire but mr mr hauken stated the debris would be unlikely to have
01:30:59 debris would be unlikely to have affected the operation of the switch had an express drop key of the correct dimensions being used in his opinion the firefighters failed to operate the switch correctly
01:31:10 to operate the switch correctly since the lfb was aware that a drop key was used across the tmos property portfolio
01:31:16 portfolio it could have tested the switch with the key when it visited grenfell tower
01:31:23 while mr halkins has suggested that project 2 was a missed opportunity to consider upgrading for the tmo miss opportunity for the timothy to consider whether it was possible to upgrade the lifts to full
01:31:34 possible to upgrade the lifts to full fire fighting standards and they should have considered the possibility at this stage
01:31:40 stage no industry professional involved in the refurbishment project brought this to the attention of the tmo which mr halkin suggested they should have done he also states it would have been good practice for peters to have highlighted
01:31:52 practice for peters to have highlighted to the tmo that the lift should be a full fire fighting lift far as it was reasonably practical this did not happen as partly to explain why the lists were not upgraded in the
01:32:04 why the lists were not upgraded in the way it suggested so importantly colin todd said told the inquiry that london to use his words is a wash with buildings that have fireman's lifts and probably a
01:32:16 that have fireman's lifts and probably a day does not go past without a fire and rescue service somewhere in the country using a fireman's lift now touching on the question of tiana's tmo policies on firefighting lips
01:32:29 tmo policies on firefighting lips sabos was aware that the tmo lifts did not have all of the features of firefighting lifts and drafted the tmo statement to lift which was recorded thereafter in the fire risk assessment
01:32:41 thereafter in the fire risk assessment the 2015 16 and 17 fire safety strategies also clearly outlined the criteria that tmo is applying to fire fighting lips
01:32:52 fighting lips while the tmo accepts the statement had theoretical capacity to confuse it is submitted that it should have been relatively clear that the lifts did not meet the full firefighting lift criteria
01:33:04 meet the full firefighting lift criteria and were not being held out as such especially to professionals reading the fire risk assessments the lfb was in fact informed that tmo's lifts were not fire fighting lifts on
01:33:15 lifts were not fire fighting lifts on multiple occasions and matthew ramsey noted in all evidence that by looking at the lift i quote again i didn't believe that they were modern standard firefighting lifts the tmo also attended various
01:33:27 the tmo also attended various familiarization sessions at grenfell tower and across the tmos housing stop where they would take control of lift of the lifts using the fire control switch and drop key
01:33:38 and drop key finally and significantly submitted roger anthony of apex told the inquirer that he had never seen a fully compliant firefighting lift in any local authority building which is
01:33:50 any local authority building which is supported we submitted colin todd's evidence that he had never seen a block of flats with an evacuation lift and so now lastly dealing with the topic on gas rises at grenfell tower before i
01:34:02 on gas rises at grenfell tower before i come on to my conclusions by the time of the fire caden had reinstated the gas supply at grenfell tower by the new riser but the boxing of the laterals in the
01:34:13 but the boxing of the laterals in the lobries in the lobbies had not been completed cadence as a statutory undertaker had the right to carry out works without obtaining planning permission
01:34:24 permission and or and or without the need to consult relevant stakeholders under the notifiable cdm design and build project for the replacement of the riser
01:34:34 riser caden was the client and trio was the principal designer and principal contractor the tmo held no cdn role and was not a party to the arrangement
01:34:45 was not a party to the arrangement in fact it had been the tmo's preference to buy out the gas thereby allowing residents to switch to electronic appliances and prevent further intrusive works taking place at grenfell tower
01:34:56 taking place at grenfell tower but in november 2016 caden decided that and i quote again a buyout was unachievable as it was unlikely that the required agreement of all gas users in the tower would be
01:35:08 all gas users in the tower would be obtained as the majority of them still use their gas supply mr dolan mr dolan suggested the tmo restricted to trio forgive me from putting the riser
01:35:20 trio forgive me from putting the riser on the external facade of the building but in fact it was never feasible to put it there as all the available space was occupied by residential accommodation and there were no common parts under
01:35:31 and there were no common parts under which the riser could be placed short of the riser running through residents homes which was impractical and undesirable there was therefore no other practical route for the communal
01:35:42 other practical route for the communal pipework
01:35:44 pipework struggling to find another solution thus it was that trio requested permission for the pipe to be installed in the stale of grenfell tower advising the tmo was the most prudent way forward and i quote
01:35:56 and i quote mr dolan also said the tmo approved the design but this incorrect not least because the tmo had no design responsibility
01:36:07 responsibility trio thought they did not need to make an application to building control in relation to the works which beryl menzies said was wrong in fact she considered the proposed works were in breach of the building
01:36:18 works were in breach of the building regulations as the works made and i quote again made the situation worse in terms of fire safety
01:36:25 safety on the basis that again to quote to have a combustible gas supply and the only escape route and the fire fighting shaft is very bad practice trio represented the tmo that it would
01:36:37 trio represented the tmo that it would carry out the work safely its emails contain the sign off we work safely or not at all the tmo did raise safety concerns with trio tasking carl stokes with attending
01:36:48 trio tasking carl stokes with attending site and commenting on the news new riser and in an email dated the 10th of february 2017 trio told the tmo in response in response to safety concerns raised i
01:37:01 response to safety concerns raised i quote
01:37:02 quote once the pipe network is installed we will box in to provide fire protection and seal holes that are not needed to provide a flow of air through the box sections
01:37:12 sections on completion of our work we will provide documentation to confirm the fire worthiness of our insulation mr dolan accepted it was trio's responsibility to evaluate the safety
01:37:23 responsibility to evaluate the safety and compliance of the risers noting that every project went through a design risk assessment but he accepted an evidence that the design risk assessment process was flawed and weak
01:37:35 assessment process was flawed and weak so the tmo acknowledges that residents including the gtla raised concerns about the gas riser and that there was a request for the appointment of an independent health and safety advisor to
01:37:46 independent health and safety advisor to consider the works the tmo did pass these concerns onto trio and the national grid and pressed them to respond as a matter of urgency it also instructed mr stokes to assess the risks
01:37:58 instructed mr stokes to assess the risks and sought further advice from him as the work progressed he prepared a report which was passed on to trio and the national grid janice ray contacted building control
01:38:11 janice ray contacted building control and they said they would generally not be involved in such projects unless there was an impact on the means of escape she advised them the work was impacted on the means of escape because the new rise was being installed in the
01:38:22 the new rise was being installed in the single communal staircase but despite this building control did not consider it needed to be involved so considering all of that information in all circumstances
01:38:33 information in all circumstances submitted dr lane's conclusion on the topic
01:38:36 topic that kctmo top management failed to seek assurance the risk to relevant persons pending completion of those works was being adequately controlled are untenable
01:38:48 are untenable and so now finally conclusions
01:38:53 so the tmo acknowledges the immense tragedy of the grenfell tower fire and nothing in these submissions is intended to diminish or detract from that tragedy
01:39:04 to diminish or detract from that tragedy the tmo submits that the evidence heard in module 3 shows its employees and officers were hard-working and diligent in their management of projects relating to grenfell tower
01:39:15 to grenfell tower including seeking the proper assurances on safety from expert contractors whom they employed or with whom as with gas providers gas providers on the national grid they had only an arm's
01:39:28 the national grid they had only an arm's length relationship while the tmo acknowledges not all aspects of its management of the active and passive fire systems were optimal whatever conclusion inquiry reaches on
01:39:39 whatever conclusion inquiry reaches on the state of repair or maintenance of those systems none was expected to perform in the extraordinary conditions that pertained on the night when non-compliant fire propagating
01:39:51 when non-compliant fire propagating products
01:39:52 products widely misrepresented and thus misunderstood have been installed it's also suggested in several of these topics the inquiry should benchmark the tiermost situation against that of other
01:40:04 tiermost situation against that of other local authorities and or social housing housing providers at the relevant time rather than holding the tier mode to a higher standard applicable only through hindsight and for example sir
01:40:17 hindsight and for example sir on the evacuation of disabled persons from high-rise general knees blocks and peeps
01:40:22 peeps the fact that this issue remains unresolved at a national level to this day
01:40:26 day demonstrates that the tmos approach was no different to that of any other uk provider of general needs social housing then or to this day the inquiry will no doubt also
01:40:38 the inquiry will no doubt also the inquiry will no doubt also carefully consider the fact that that non-compliance consider the non-compliance between the doors supplied by mance master door and their test results were not confined to
01:40:50 their test results were not confined to grenfell tower but was on a national wide scale and so can i say finally the tmo continues to offer its full support to the inquiry in fulfilling its important statutory functions
01:41:02 statutory functions and those are my submissions well thank you very much indeed mr agaros that brings us to the end of the statements that are scheduled to be given today
01:41:14 given today but tomorrow there will be a further round of statements when we shall hear from a number of other core participants but for today that's where the hearing ends
01:41:25 ends we rise now we'll resume at 10 o'clock tomorrow thank you all very much
01:42:07 you