Module 3 opening statements addressing fire safety management failures by RBKC and TMO, lack of scrutiny, failure to identify vulnerable residents, and systemic governance failures.
00:00:12 good morning everyone and welcome to today's hearing in which i am joined as usual by my fellow panel members
00:00:20 members ms thuria istafan and mr ali akbar good morning good morning everyone
00:00:28 today marks another step in the progress of the inquiry because we're going to hear opening statements in relation to module 3.
00:00:39 in relation to module 3. a number of core participants are going to make
00:00:42 to make oral statements although a greater number have also provided some written opening statements which will be available to view in due course before we hear them however i'm going to
00:00:54 before we hear them however i'm going to invite counsel to the inquiry mr richard millet
00:00:57 millet to make an opening statement of his own yes mr millett chairman thank you good morning and good morning members of the panel today we start module three of phase two
00:01:08 today we start module three of phase two of the inquiries investigation in march 2020 the inquiry set out the structure
00:01:15 structure of module three it is to be divided into three
00:01:19 three distinct but closely related topics in summary topic one will consider fire related complaints topic two will consider the extent to
00:01:31 topic two will consider the extent to which
00:01:32 which the royal borough of kensington and chelsea council rbkc and the kelsey and kensington chelsea tenant management organization the tmo complied with their respective
00:01:45 the tmo complied with their respective obligations under the regulatory reform fire safety order
00:01:49 order 2005 the rro and topic 3 will address active and passive fire safety measures within grenfell tower
00:02:00 within grenfell tower although the ambit of module 3 is broad there is a single unifying theme that is whether and to what extent
00:02:11 that is whether and to what extent rbkc and the tmo and others performed the duties they each owed in respect
00:02:19 respect of fire safety that unifying theme will be investigated from a number of different perspectives starting in topic one
00:02:30 starting in topic one with the evidence of those who lived in the tower
00:02:34 the tower it is in the inquiry's view vital that consideration of fire safety matters affecting the building
00:02:42 building and those who live there begins with the evidence
00:02:46 evidence of those whose health and safety was or could have been the primary aim of the fire safety duties of the relevant duty holders
00:02:58 relevant duty holders we will examine communications between residents and the tmo in which the residents through attention to defects in design choices materials or quality of
00:03:09 choices materials or quality of workmanship which they said increase the risk of fire
00:03:14 fire or which the evidence suggests may in the event have contributed directly or
00:03:20 or indirectly to the outbreak or development of the fire that examination will be conducted
00:03:28 conducted through the live evidence of residents and by reading into the record relevant extracts from bsr's statements and consideration of contemporaneous documents
00:03:40 documents the examination will pass light on the nature of the relationship in particular between rbkc and the tmo on the one hand and residents of the
00:03:51 on the one hand and residents of the tower
00:03:51 tower on the other in particular the evidence will focus on whether the tmo's response to residents concerns regarding fire safety before the 14th of june 2017
00:04:04 safety before the 14th of june 2017 was appropriate and effective after the residence evidence the inquiry will then hear from those at the tmo who were responsible for
00:04:15 responsible for who or who were involved in consideration of complaints concerning fire safety matters whether operationally strategically or otherwise and also from
00:04:26 strategically or otherwise and also from others
00:04:27 others such as rbkc councillors and other officers
00:04:30 officers of rbkc who were responsible for scrutinizing the pmo's activities and for discharging our vkc's own via safety related duties
00:04:43 our vkc's own via safety related duties in that respect the inquiry notes and welcomes
00:04:47 welcomes the various admissions made by rbkc in its opening statement in particular the inquiry notes rbkc's acknowledgment that the number of its officers devoted
00:04:59 that the number of its officers devoted to monitoring the dmo was insufficient given the number of residents
00:05:04 residents whose properties were managed by the tmo and the scale and importance of the tasks delegated to the pma rbkc has also made other concessions and admissions
00:05:16 concessions and admissions in its written opening statement for which the inquiry team is grateful for example has recognized that as part of its arrangements for
00:05:27 that as part of its arrangements for scrutinizing the dmo it never made fire safety the subject of a key performance indicator it has also accepted that its audit arrangements consistently
00:05:38 arrangements consistently fail to identify the absence of key performance indicators governing the tmos completion of fire risk assessments outstanding significant actions identified in fire risk assessments
00:05:50 identified in fire risk assessments or enforcement of deficiency notices served
00:05:53 served by the london fire and emergency planning authority on any view these are significant deficiencies in rbkc's arrangements for monitoring
00:06:04 in rbkc's arrangements for monitoring and scrutinizing the effectiveness of the tmos compliance with
00:06:08 with its fire safety obligations the inquiry also notes that the tmo has made no concessions in its opening statement whether that remains its position following the
00:06:20 remains its position following the conclusion of the evidence will remain to be seen whether the concessions by rbkc go far enough
00:06:28 enough will be an important question when the inquiry turns into topic 2 to consider the extent to which those bodies
00:06:35 bodies performed their respective obligations imposed under the rro inevitably this aspect of the inquiry's investigation will be wide-ranging we'll examine
00:06:46 will be wide-ranging we'll examine the adequacy of the tmo's management of fire safety and the effectiveness of its arrangements for carrying out fire risk assessments we will also investigate the competence of mr carl stokes
00:06:57 of mr carl stokes the tmo's retained fire risk assessor and the adequacy of his fire risk assessments but in particular the adequacy of his advice regarding the cladding
00:07:09 regarding the cladding and the pmo's consideration of that advice
00:07:13 advice we'll also consider and investigate the acts
00:07:16 acts and emissions of those responsible for implementing supervising monitoring and scrutinizing the effectiveness of the pmo's fire risk assessment arrangement the evidence will focus on
00:07:29 arrangement the evidence will focus on three principal questions first whether the tmo maintained an adequate
00:07:36 adequate evacuation plan for the tower or identified those residents of the tower who were vulnerable and if not why not whether it assessed the risks that those individuals would
00:07:47 the risks that those individuals would face in the event of a fire or take steps to mitigate those risks but if not why not importantly whether the tmo ever prepared personal
00:08:00 whether the tmo ever prepared personal emergency evacuation plans or pete the vulnerable residents of the tower
00:08:08 tower if not why not we will focus on whether there was a suitable and sufficient fire risk assessment program for grenfell power
00:08:20 grenfell power including the effectiveness of the arrangements for ensuring that significant actions identified in fire risk assessments or fras were implemented efficiently effectively
00:08:33 were implemented efficiently effectively and expeditiously thirdly whether the arrangements for maintaining active and passive fire safety systems were effective with particular attention
00:08:45 particular attention to the inspection and maintenance of self-closing devices on flat entrance doors in the power factual evidence regarding fire risk assessment will be followed
00:08:57 assessment will be followed in topic 3 by consideration of the active and passive fire safety measures in the tower and and will do so in the following order
00:09:07 order gas remote control repairs and maintenance fire doors especially flat entrance doors
00:09:15 doors and lifts experts have been retained to assist the inquiry's investigation of gas
00:09:22 gas smoke control and lifts that expert advice will be abused after the factual evidence that is relevant to each of those matters that have been heard so mr hancock's
00:09:33 that have been heard so mr hancock's evidence will follow that of the food gas witnesses the evidence of dr lane and miss menzies on smoke control will follow that of the smoke control witnesses
00:09:43 witnesses and mr hawkins's evidence on lifts will follow that of the factual witnesses about lifts model 3 will conclude with the evidence of mr colin todd
00:09:55 of mr colin todd and dr barbara lane on fire risk assessment there are some housekeeping matters that i should highlight first the inquiry will not sit on the 14th of june this year
00:10:07 14th of june this year which will be the fourth anniversary of the fire
00:10:11 the fire we will not sit on that day out of respect for those who died and to allow those who grieve to remember their loved ones and for all of us to reflect privately on the cabinet
00:10:23 on the cabinet secondly the inquiry will not sit on the two bank holidays that fall in may thirdly the inquiry secretary has written to four participants setting out the plans
00:10:34 the plans for attendance at the inquiry's venue as matters currently stand we will restart limited attendance hearings at the inquiry's premises at the start of the witness evidence for
00:10:46 at the start of the witness evidence for module 3
00:10:47 module 3 that will be on monday the 19th of april in order to comply with government restrictions and the risk assessment for the building which has been carried out by the government property agency
00:11:00 government property agency attendance will need to be strictly limited at that stage in exactly the same way as it was before christmas
00:11:08 christmas uh to the panel council to the inquiry the witnesses and their representatives have a small inquiry operations and support team if government restrictions then commit
00:11:21 if government restrictions then commit after the 17th of may we plan to open the inquiry premises more widely our first priority being to allow a number of bsrs to attend to watch the proceedings in
00:11:32 to attend to watch the proceedings in person
00:11:34 person we are giving careful thought to the practicalities of how we can do that both safely and fairly and the inquiry secretary will write the court participants further about
00:11:45 the court participants further about that in due course
00:11:49 we will have to consider further relaxation of the measures governing attendance at the premises in the light of any ongoing government restrictions and guidance in force over the summer we will of
00:12:00 in force over the summer we will of course
00:12:01 course keep core participants and the wider public
00:12:04 public informed of our plans broadly jonathan sakula the inquiry's planning expert will give evidence on thursday the 29th of april for one day
00:12:16 of april for one day mr sacula's evidence is relevant to module one and so to allow core participants to complete the drafting of their written posing statement for module 1 the inquiry has decided to
00:12:28 for module 1 the inquiry has decided to call mr stakula as soon as this schedule and the inquiry's timetable allows quickly and finally the expert evidence of dr
00:12:37 of dr lane and miss menses concerning smoke control
00:12:41 control will be disclosed as soon as possible the inquiry will then give directions for the service of written opening statements on the topics of smoke control and a half day has been allowed for oral
00:12:53 and a half day has been allowed for oral opening statements on that topic we will keep more participants and the public updated as we go mr chairman members of the panel that concludes my opening statement for
00:13:05 that concludes my opening statement for module three thank you very much mr millet well at that point uh i am in a position to invite uh miss stephanie barwise uh to make an
00:13:17 uh miss stephanie barwise uh to make an opening statement on behalf of those bereaved survivors and residents whom she represents now miss barwise can you tell me whether
00:13:28 now miss barwise can you tell me whether you are in contact can you see me and can you hear me good morning mr chairman yes i can ah good morning good well um we're all ready to go if you are
00:13:39 you are and so thank you so take your time and um
00:13:43 um make your statement when you're ready thank you and good morning mr miss estefan and mr akbar you have our written submissions on all three topics within module three
00:13:54 within module three i propose to address you on aspects of topics one and two but we'll first summarize the module and its themes module three is a tale of lessons
00:14:05 module three is a tale of lessons unlearned
00:14:06 unlearned despite the teaching of successive fires the failure of the physical and managerial controls at grenfell which should have mitigated the extent of fire
00:14:16 of fire was as predictable as it was preventable central to ensuring these controls are adequate
00:14:24 adequate are the fire risk assessments required by the regulatory reform fire safety order 2005 which should have informed
00:14:32 informed rbkc and tmo of the measures required to mitigate
00:14:37 mitigate fire and to facilitate evacuation the principal managerial failures at grenfell included a failure to identify the occupancy profile coupled with a lack of any emergency or
00:14:50 coupled with a lack of any emergency or evacuation plan still less evacuation plans for the disabled
00:14:56 disabled peeps weaknesses in the physical controls such as compromised compartmentation including defective fire doors rendered the stay put strategy lethal
00:15:08 the stay put strategy lethal and impacted the means of escape these failings materially contributed to the extent and severity of the disaster the bereaved survivors and residents
00:15:21 the bereaved survivors and residents from whom the inquiry will hear are but a few of the many residents who made up a richly diverse community their diversity is highly relevant to module 3 issues
00:15:33 module 3 issues since age disability and ability to read english
00:15:37 english are all factors which should have informed
00:15:40 informed both the assessment of the degree of risk
00:15:43 risk and potential harm posed by fire and accordingly the fire safety measures at grenfell a significant proportion of residents suffered from some form of disability or
00:15:56 suffered from some form of disability or were vulnerable which should have been addressed when considering the means of escape and evacuation strategy both tmo and its fire risk assessor carl stokes
00:16:07 and its fire risk assessor carl stokes failed to identify vulnerable residents at grenfell despite this being a recognized parameter in fire risk management as the risk profile of a building
00:16:18 profile of a building is a function of its occupancy and fire growth rate there is no evidence that tmo assessed the needs of any vulnerable person in grenfell in the
00:16:29 any vulnerable person in grenfell in the event of
00:16:30 event of fire this failure resulted in tmo not recognizing the fire precautions required to protect vulnerable residents and failing to advise lfb of the need to
00:16:41 and failing to advise lfb of the need to assist the vulnerable the lack of appropriate precautions is reflected
00:16:47 reflected in the deaths dr lane calculates that a quarter of the 67 child residents present on the night died
00:16:56 died and 41 of the 37 vulnerable adult residents died these groups suffered higher death rates than any other on the night yet tmo's spreadsheet
00:17:09 on the night yet tmo's spreadsheet emailed during the fire showed only 10 residents with disabilities out of 225 listed in this respect grenfell shines a light on an aspect of
00:17:21 grenfell shines a light on an aspect of fire safety crying out for reform dr lane considers there is an urgent need for guidance and focus on the fire risk assessments or fras for the vulnerable in the event of
00:17:34 fras for the vulnerable in the event of fire
00:17:35 fire three key themes which span across the topics which the inquiry will wish to explore include first rbkc's leadership culture and purpose insofar as they
00:17:46 culture and purpose insofar as they influenced fire safety and engagement on that subject with residents
00:17:51 residents second rbkc's scrutiny of tmo and third tmo's fire safety management starting with the first theme rbkc's leadership and its influence on fire
00:18:03 leadership and its influence on fire safety
00:18:04 safety rbkc's prioritization of cost over fire safety
00:18:09 safety is a contributing factor to the extent of the disaster appointing tmo as an arms length management organisation or almo did not relieve rbkc of its common law
00:18:21 did not relieve rbkc of its common law duties as landlord nor of its statutory duties including responsibility under the fire safety order
00:18:29 order rbkc's failure to show leadership and adopt a rigorous approach to fire safety management inevitably affected tmo's approach as lord cullen found in his lab grove
00:18:41 as lord cullen found in his lab grove rail crash inquiry report a successful safety culture depends upon the leadership driving that agenda it has long been clear as stated in the
00:18:52 it has long been clear as stated in the 2007 good governance framework that it is the role of a local authority's leadership to clearly articulate its vision of its purpose
00:19:02 purpose and intended outcomes for its citizens rbkc accepted this principle by its 2014 by borough corporate fire safety policy
00:19:13 by borough corporate fire safety policy which expressed its desire to champion fire safety through strong visible leadership far from championing fire safety our bkc
00:19:24 far from championing fire safety our bkc prioritized cost over safety on leaseholder doors door closers and sprinklers it seems if the lfb had made a firm recommendation or requirement for sprinklers
00:19:35 sprinklers rbkc would have considered it this is to misunderstand that the fire safety order required rbkc to make its building safe for the residents thus
00:19:46 its building safe for the residents thus different buildings require different measures
00:19:50 measures rbkc failed to prioritize fire safety and refurbishment despite the lachenal house coroner's 2013 recommendations rbkc's leader
00:20:02 2013 recommendations rbkc's leader councillor padgett brown failed to implement the lfb audit tool sent to him in 2015 which was specifically designed to ensure refurbishments did not impact fire safety and had been designed
00:20:15 impact fire safety and had been designed by the lachenal house working group for adoption by councils this criticism does not derive from mere hindsight rbkc was aware of the lachenal fire issues from july
00:20:28 lachenal fire issues from july 2009 and acutely so from 2013 when it considered the coroner's recommendations in 2014 rbkc's building control received
00:20:40 in 2014 rbkc's building control received notes on lacanal warning it could happen again in social housing citing cladding and overall worsening of conditions through years of neglect
00:20:51 through years of neglect despite these warnings rbkc did not issue guidance to its almo on such matters as late as april 2017 rbkc's laura johnson received lfb's
00:21:03 rbkc's laura johnson received lfb's letter
00:21:04 letter entitled tall buildings external fire spread
00:21:08 spread warning that cladding panels often did not comply with building regulations were prone to delaminating and could potentially spread fire from flat to flat
00:21:19 flat the letter urged rbkc to address how it achieved compliance and consider this issue as part of the risk assessment process for premises under your control rbkc
00:21:32 under your control rbkc failed to investigate how tmo ensured compliance of facades but contrary to lfb's advice rbkc also failed to require that facades should be included in future fire risk
00:21:45 should be included in future fire risk assessments this despite grenfell's recent refurbishment and it being one of our bkc's highest risk properties instead rbkc forward lfb's letter to tmo
00:21:59 instead rbkc forward lfb's letter to tmo without instruction simply fyi this lack of proactivity is extraordinary in a project rbkc witnesses describe as a big deal
00:22:11 rbkc witnesses describe as a big deal widely seen as a positive thing by our bkc officers only after the fire did rbkc issue a draft fire safety management system which finally acknowledged the need for
00:22:23 which finally acknowledged the need for housing management to comply with existing guidance by preparing fire strategies for existing buildings in accordance with past 9 11 and put in place a robust
00:22:34 place a robust system of fire risk assessments to industry best practice under past 79 the failure to require such strategies and systems before the
00:22:45 such strategies and systems before the fire
00:22:45 fire is a serious failing given dr lane's opinion
00:22:49 opinion that it is impossible for the responsible person to discharge their fire safety duties without an existing fire safety strategy which would inform the significant findings in fras
00:23:02 findings in fras the inquiry will need to determine the question whether both rbkc and tmo were responsible persons under the fire safety order both qualify since as occupier
00:23:13 both qualify since as occupier or otherwise both have significant control
00:23:17 control in the carrying on of an undertaking namely housing provision tmo's fire safety strategies consistently from october 2012 to june 2017
00:23:28 2017 described itself and our bkc as both being responsible persons as from 2010 lfb regarded rbkc as a responsible person
00:23:40 rbkc as a responsible person rbkc acknowledged its responsibility as a responsible person by participating with tmo and lfb in the 2009 program to improve fire safety of rbkc stock
00:23:54 fire safety of rbkc stock while tmo had day-to-day control rbkc had
00:23:58 had ultimate control since tmo's funding entirely derived from rbkc the second theme is the quality and degree of rbkc's scrutiny of tmo
00:24:11 degree of rbkc's scrutiny of tmo although rbkc delegated various functions to tmo by virtue of section 27 of the housing act 95 1985 right to manage regulations and
00:24:22 1985 right to manage regulations and form of agreement approved by the secretary of state under those regulations namely the modular management agreement or mma
00:24:30 or mma rbkc's legal relationship with its tenants or leaseholders and its statutory
00:24:36 statutory contractual and common law obligations towards them remained rbkc was obliged to scrutinize tmo's exercise of those functions
00:24:47 tmo's exercise of those functions delegated it in order to ensure compliance with the fire safety order and the council's common law duties
00:24:55 duties rbkc also had a scrutiny function under the localism act 2011. the four core principles of good scrutiny proposed by the center for public
00:25:07 proposed by the center for public scrutiny provide for critical friend challenge enabling the voice and concerns of the public in a process led and owned by independent-minded councillors which
00:25:20 by independent-minded councillors which drives
00:25:21 drives improvement in public services rbkc's principal vehicle for scrutiny of tmo was the mma but it lacked specificity as to the degree of monitoring
00:25:33 degree of monitoring rbkc was entitled or obliged to carry out
00:25:37 out the key mechanism for scrutiny under the mma was the setting of key performance indicators or kpis but rbkc failed to ensure there were kpis governing
00:25:49 kpis governing safety despite fire safety always being a pressing criterion for rbkc given the vulnerable tenants it housed this link between vulnerable tenants and
00:26:00 this link between vulnerable tenants and fire outcomes is enshrined both in british standards governing the design and use of buildings
00:26:07 buildings and other guidance the failure is also surprising given rbkc mooted accessibility for the disabled
00:26:14 disabled as a possible kpi in an internal email in 2009
00:26:20 in 2009 noting there are some serious brownie points to be gained in all this as members understandably feel
00:26:27 feel very strongly about disability and meeting need the failure to ensure fire safety kpis were in place is all the more extraordinary given that as rbkc knew tmo was
00:26:40 given that as rbkc knew tmo was proposing kpis for fire for its own monitoring purposes from 2015 onwards albeit they were never in fact
00:26:48 in fact implemented rbkc admits as council's inquiry has said by its opening submissions that it should have imposed kpis on tmo for fras and work required under
00:27:01 on tmo for fras and work required under them
00:27:03 them there was an appearance of scrutiny but it lacks substance our bkc's yearly and half yearly reviews of tmo's compliance with kpis were based on reports the vast majority
00:27:16 were based on reports the vast majority of which
00:27:16 of which rbkc now admits were written by tmo this was also true of the health and safety reports which tmo's health and safety advisor janice ray had prepared
00:27:28 safety advisor janice ray had prepared thereby marking her own homework rbkc candidly admits that this fact was not
00:27:34 not made clear to those scrutinizing and should have been rbkc also admits that the number of officers devoted to monitoring tmo was insufficient given the scale of the
00:27:46 was insufficient given the scale of the task delegated to tmo and that in certain key respects our bkc's monitoring of tmo was not carried out in accordance with rbkc's own
00:27:57 out in accordance with rbkc's own monitoring procedure guide rbkc also admits that it failed to convene the six weekly meeting with tmo's complaints team
00:28:08 team rbkc was aware at latest from 2010 of its responsibility to take a hands-on role in fire safety rather than simply relying on paper briefings from its almo
00:28:20 briefings from its almo rbkc endorsed a note called extinguishing the risk a councillor's guide to fire safety at a scrutiny meeting in 2010 that guide made clear that a
00:28:32 in 2010 that guide made clear that a council's responsibility whether for retained stock or via an almo
00:28:37 almo was the same as any other landlord namely that the council needed to ensure the fire strategy was being taken seriously and fras done competently
00:28:48 competently the scrutiny committee recorded that the guide reflected the expectations on this council the third theme is tmo's fire safety management
00:28:59 management the adequacy of this requires close examination the responsibility for fire safety across our bkc's entire estate of some 9400 properties
00:29:10 9400 properties rested on janice ray as health and safety manager dr lane considers ray should have been capable of designing and delivering a fire risk management system and if not should have sought assistance
00:29:23 and if not should have sought assistance while lane finds tmo's policy documents did address some relevant fire safety objectives they failed to plan how to achieve their policy intent
00:29:34 how to achieve their policy intent critically tmo failed to identify its intent in relation to occupancy profiling and although some monitoring was done there is no evidence that this was done
00:29:45 there is no evidence that this was done to inform the rfas furthermore tmo failed to articulate its intent as to the implementation of general fire precautions and control of construction work as a
00:29:57 and control of construction work as a result
00:29:58 result these activities were haphazard these fundamental failures were compounded by tmo's reliance for all aspects of fire safety advice at grenfell on a single risk assessor stokes
00:30:11 on a single risk assessor stokes who lacked any professional registration and invented some of his professional qualifications tmo was overwhelmed by the sheer volume of outstanding fra actions due to its
00:30:24 of outstanding fra actions due to its failure to address how they should be actioned as a result it sought to deliberately conceal this from rbkc
00:30:33 from rbkc tmo's focus on completion of our fra action items without monitoring the level of risk posed thereby is a critical failing this problem originated with stokes
00:30:44 this problem originated with stokes whose fras did not state the impact on risk if tmo failed to undertake
00:30:50 undertake the actions he identified within the required time scale in turn stokes failed to interrogate tmo's fire safety management or maintenance regime
00:31:01 maintenance regime which meant that his opinion of the consequences of a fire and overall risk level could never be accurate
00:31:08 accurate critically tmo failed to monitor stokes's activities despite being aware that a different fire resist fire risk assessor in 2014 had taken a
00:31:19 fire risk assessor in 2014 had taken a different approach giving grenfell a moderate as opposed to tolerable risk pending resolution of his action items this should have alerted tmo to stokes
00:31:31 this should have alerted tmo to stokes his failure to evaluate the risk posed by outstanding fra items stokes's failings were absolutely plain by the time of the adair fire in 2015
00:31:42 2015 and ray received various criticisms of him in 2016 and 2017 yet tmo failed to question the performance of the risk assessor on whom they were very heavily dependent
00:31:56 on whom they were very heavily dependent as to the first topic complaints a functional complaints process is a key element of the four core principles of scrutiny i've already mentioned complaints help inform management of
00:32:08 complaints help inform management of true performance tmos and rbkc's dismissive attitude towards residents complaints was symptomatic of their approach to governance
00:32:19 governance which led directly to the devastating failures of controls at grenfell tmo avoided classifying expressions of dissatisfaction as complaints
00:32:30 complaints characterizing them instead as service requests
00:32:33 requests the complaints policy contemplated an investigation procedure of up to three internal stages creating the illusion that complaints would be considered afresh
00:32:43 afresh at each stage whereas in fact responses to complaints were drafted by those complained about but sent out by others in tmo giving a semblance of
00:32:54 others in tmo giving a semblance of impartiality the first two stages were subsequently amalgamated following instructions from tmo's ceo
00:33:02 tmo's ceo robert black in 2014 to make sure we are all on the same page residents considered the process unduly cumbersome and difficult to navigate
00:33:14 cumbersome and difficult to navigate during the refurbishment residents were initially referred to ryden before engaging tmo's own process such that as tmo's then complaints manager joanne burke noted
00:33:26 manager joanne burke noted by the time that they get to the complaints team they are thoroughly fed up
00:33:31 up burke also felt that there is a defensive culture in the capital team about complaints tiano's approach decentralized complaints madison's descriptions of closing down
00:33:43 madison's descriptions of closing down closing off or shutting down complaints reflect tmo's strategy of merely dealing with complaints but without genuine consideration
00:33:54 consideration resident concerns were dismissed as rhetoric
00:33:57 rhetoric madison dismissed dafon and o'connor's gag blog
00:34:00 gag blog as scam-mongering following a residence petition in 2015 asking rbkc to exercise scrutiny
00:34:09 scrutiny tmo in collusion with rbkc officers and counsellors engineered a situation where tmo could deal with itself and avoid scrutiny by rbkc
00:34:20 and avoid scrutiny by rbkc the resulting tmo board report lacked independence and failed to address residents complaints tmo briefed councillors against residents making clear complaints had been
00:34:32 making clear complaints had been rejected were without foundation and suggesting residents had acted unreasonably this concerted effort to manage councillor's perceptions of tmo came from the top it was led by black
00:34:45 came from the top it was led by black who cultivated a relationship with rbkc's laura johnson which gave him advice and influence over councillors johnson's march 2017 email in response
00:34:56 johnson's march 2017 email in response to blacks about a post refurbishment complaint
00:34:59 complaint in which he characterized the complaint as an
00:35:02 as an echo of the fight we have been in for the last two years epitomizes her advice and her negative attitude
00:35:10 attitude towards grenfell residents she said be robust
00:35:14 robust to councillor fielding mellon he's not minded to attend a public meeting with a group of people who are moaning about minor issues he is fully aware about eddie daffan so you can rest assured he is not taken
00:35:26 you can rest assured he is not taken seriously
00:35:28 seriously this doesn't go back two years this goes back 20 years it has always been a bad tempered place and for some reason that general crossness
00:35:37 crossness has lingered and is stoked by various individuals with their own agenda understandably residents were not fire safety experts but they did identify
00:35:48 but they did identify three important issues which should have alerted tmo to an obvious threat to grenfell's fire safety first the replacement riser in the stairwell
00:35:59 replacement riser in the stairwell tmo procured the installation of the riser by national grid following a leak in a gas riser in 2016. between march and may 2017 residents including lee
00:36:10 including lee chapman secretary of the grenfell tower leaseholders association voiced concern about the fire safety of installing gas pipes in their only escape route and repeatedly asked that an independent
00:36:23 and repeatedly asked that an independent expert be engaged these concerns were well founded tmo had been warned by stokes's letter in january 2017 to ensure that compartment penetrations
00:36:35 to ensure that compartment penetrations were sealed and that an application to building control for the works was required yet both rbkc and tmo instead relied on vague assurances of
00:36:46 instead relied on vague assurances of compliance resident concerns were dismissed with division
00:36:51 division epitomized by laura johnson in march 2017
00:36:55 2017 lee chapman had given johnson and black a clear and correct warning that as a result of the installation the building's integrity has been compromised mr chapman's email
00:37:07 has been compromised mr chapman's email also
00:37:08 also alerted johnson black to grenfell's vulnerable residents there are many people in this building who are immobile very young or suffer from mental health issues
00:37:18 issues a moment's reflection particularly in the wake of lachenal should have caused these senior figures in tmo and rbkc to reflect on the possibility of
00:37:29 to reflect on the possibility of compartment breach and should have served as a timely reminder of the needs of vulnerable residents which had not been addressed instead johnson told black when the pipe
00:37:41 instead johnson told black when the pipe issue has gone away they will find something else to write about
00:37:46 about second reports of broken door closers or damage to seals on flat entrance doors should also have alerted tmo yet did not daffan's complaint in august
00:37:57 yet did not daffan's complaint in august 2015 that flat 136's door had been left open all weekend
00:38:01 weekend and had a broken door closer was met with the suggestion that he simply closed it
00:38:07 closed it gmo considered the issue resolved this overlooked the fundamental problem that open doors equate to breached compartmentation betty cassotti and others record that
00:38:18 betty cassotti and others record that when their doors were reported as difficult to close tmo's repairing contractor simply removed the closer third the lift although residents complaints including those with
00:38:30 complaints including those with disabilities concerned the inconvenience of breakdowns rather than safety and fire
00:38:35 fire these complaints were obvious alerts to the dependence of those with disabilities on the lift this should have triggered further investigation as to the use of lifts as evacuation
00:38:46 as to the use of lifts as evacuation lifts
00:38:47 lifts and the need for peeps turning to topic two
00:38:51 two the fire safety order imposes a requirement that a building regardless of age or compliance with regulations be safe for the relevant persons namely residents and visitors
00:39:03 residents and visitors this is achieved by procuring fras to identify the preventative and protective measures
00:39:08 measures required to keep relevant persons safe an evacuation plan is necessary in certain circumstances such as compartment breach regardless of the evacuation strategy of
00:39:20 regardless of the evacuation strategy of the building and including if it is stay put
00:39:24 put the inquiry will wish to address how it is that one of the principal pieces of guidance applicable to purpose-built blocks approved by the secretary of state detracts in key respects from
00:39:35 detracts in key respects from obligations imposed by the order this lga guide was sector-led and albeit produced in the wake of lachanel fails to require an evacuation strategy
00:39:46 fails to require an evacuation strategy and
00:39:47 and assumes that peeps are not required in general needs blocks the guide also created the concept of a notional fd30 door namely one with an assumed fire
00:39:58 namely one with an assumed fire resistance of 30 minutes and suggested it was not practical to destructively test a door in order to establish the actual fire resistance of doors for which no certification now
00:40:10 of doors for which no certification now existed
00:40:11 existed this ran counter to other post-lachimal guidance by the leasehold excellence network
00:40:18 network despite incorporating past 79 by reference
00:40:21 reference the lga guide runs counter to path 79 methodology for preparing an fra the inquiry will wish to explore the divergence of its two experts dr lane and mr todd as to the
00:40:34 experts dr lane and mr todd as to the adequacy of stokes as fras and on the topic of legislative requirements for people with disabilities on which todd's views are at odds with the requirement of the fire safety order
00:40:46 the requirement of the fire safety order todd's vindication of stokes is we suggest unlikely to withstand scrutiny and begs the question whether the competent standard for fire risk assessors is far too low dr lane concludes that
00:41:00 is far too low dr lane concludes that stokes
00:41:01 stokes erred in four key respects first failing to identify the occupancy profile of the building which is both a failure to identify the relevant persons and a failure to evaluate the risks to
00:41:13 and a failure to evaluate the risks to those persons and necessary mitigation second failure to link his proposed corrective measures to the risk they posed if not cured
00:41:24 to the risk they posed if not cured third failure to probe tmo's fire safety management in order to evaluate the risks fourth failure to request and review the imagined emergency plan for evacuation
00:41:36 imagined emergency plan for evacuation these failures meant he failed to assess the risks posed by grenfell to residents and visitors and his risk rating of tolerable should have been
00:41:46 have been intolerable stokes's treatment of the facade was also flawed while there is a debate as to whether a risk assessor must assess the facade given that the fire safety order does
00:41:58 given that the fire safety order does not define the external wall as a common part
00:42:02 part both schedule one part three of the order and the approved methodology past 79
00:42:08 79 require risk assessors to evaluate the risks which cannot be avoided that includes factors such as combustible facades which should be included in the significant findings
00:42:20 significant findings in any event stokes by his fras purported to have assessed the cladding describing it as fire rated a meaningless term but he also suggested compliance with
00:42:31 but he also suggested compliance with fire with building regulations it is now clear from stokes's statement that he did not know what the composition of the cladding was and therefore had not assessed the risks
00:42:42 and therefore had not assessed the risks posed by it stokes his treatment of lifts was deplorable in 2009 he reported that he didn't know whether the lifts were firefighter or evacuation
00:42:53 the lifts were firefighter or evacuation lifts
00:42:53 lifts but his 2010 and all subsequent fras described both as evacuation or firefighter lifts which could be used to evacuate disabled residents
00:43:04 residents this despite stokes having been told that tmo's senior lift engineer did not consider the grenfell lifts to be firefighter lists again dr lane and mr todd's opinions are
00:43:15 again dr lane and mr todd's opinions are in sharp contrast while both agree stokes did not understand lyft's standards lane considers his failure to recognize the lifts were not firefighter lifts resulted in the loss
00:43:27 firefighter lifts resulted in the loss of a vital opportunity to identify necessary mitigating measures
00:43:32 measures todd however considers stokes's lack of knowledge of lift standards does not detract from his competence as a fire risk assessor and that the list design did not affect
00:43:43 and that the list design did not affect the risk to relevant persons that is unlikely had the lifts been firefighter lists either no key at all would have been required or an emergency unlocking triangle key
00:43:55 or an emergency unlocking triangle key would have been required and in either case it would not have been possible to use the incorrect key which howkins tentatively concludes is most likely what happened
00:44:07 most likely what happened at least three lives might have been saved
00:44:11 saved perhaps stokes's most egregious failing was not to ask for an evacuation plan or address the lack of peace instead he repeated for six years that data would be inputted into a
00:44:23 years that data would be inputted into a tp tracker with a view to preparing peeps
00:44:26 peeps but as he knew he had not been asked to prepare peeps for grenfell lane considers he should have been proactive in obtaining such information rbkc and tmo's principal
00:44:38 information rbkc and tmo's principal failures as to the res as a responsible persons related to fire doors and failures to facilitate evacuation of the disabled tmo's fire risk management suffered from
00:44:50 tmo's fire risk management suffered from systemic
00:44:51 systemic failures despite tmo being told in 2009 that it was in statutory breach on almost half of the procedures reviewed the review advised tmo it needed a fire
00:45:03 the review advised tmo it needed a fire safety policy setting objectives for compliance with the fire safety order tmo suffered from a lack of transparency which meant it lauded itself as having been given a clean bill of health
00:45:15 been given a clean bill of health by external audits in 2013 even though those audits had alerted tmo to its poor management systems tmo did not have proper structures in
00:45:26 tmo did not have proper structures in place to address the volume of action items arising from fras but rather than resolving the issues resorted to cleansing the revealing data this lack
00:45:37 cleansing the revealing data this lack of transparency resulted in the fras not being a reliable review of tmo's system and not assessing risk tmo's systems did not encourage learning
00:45:48 tmo's systems did not encourage learning lessons
00:45:49 lessons or changed although labrae reported to the tmo health and safety committee concerning fire safety by high level exception reports these were not shared with the tmos
00:46:01 these were not shared with the tmos board and therefore there was no mechanism for making changes to the fire risk management system as to doors rbk saw sea sword from 2011
00:46:12 as to doors rbk saw sea sword from 2011 and still going ongoing in may 2017 to avoid using its powers
00:46:17 powers under the housing act to ensure leaseholder doors were compliant and instead sought to persuade lfb to prosecute
00:46:25 prosecute leaseholders under the fire safety order rbkc clearly recognized it was in breach of the fire safety order as it made its admission in 2013 to the secretary of state acknowledging
00:46:37 to the secretary of state acknowledging 68 potentially non-compliant doors and jointly with tmo obtained advice from council which apparently suggested tmo's notification to leaseholders
00:46:49 notification to leaseholders of non-compliance constituted due diligence
00:46:53 diligence namely a defense to successful prosecution under the order despite being acutely aware that defective doors mean compartmentation breaches rbkc's approach was to cynically
00:47:06 rbkc's approach was to cynically calculate
00:47:07 calculate potential cost versus the cost of replacing leaseholder doors in an email in which rbkc's roger keane had noted there was no realistic prospect of southwark being
00:47:19 prospect of southwark being criminally prosecuted for lachenal he said
00:47:23 said if something did happen at one of our properties we are still likely to be the organization that faces prosecution we therefore have to weigh up the potential cost of dealing with this
00:47:34 potential cost of dealing with this issue
00:47:35 issue against the situation we would face if something happened and we were found liable there can be no room for any form of cost benefit
00:47:46 no room for any form of cost benefit analysis
00:47:47 analysis given rbkc's obligation to keep the protected routes safe and given lives were at stake even as late
00:47:55 late as may 2017 when councillors suggested rbkc should replace leaseholder doors at trellic tower regardless of whether they would be reimbursed laura johnson overruled them
00:48:06 reimbursed laura johnson overruled them describing it as a non-issue this demonstrates a staggering lack of concern only tolerable in a culture with scant regard for safety
00:48:18 safety tmo also knew it was in breach of the order and had been advised by stokes that landlords were being prosecuted for non-compliant doors on the protected route it seems rbkc's
00:48:30 on the protected route it seems rbkc's and tmo's focus was on avoiding liability
00:48:33 liability instead of on fire safety rbkc was similarly irresponsible in relation to the absence of door closers cost management took priority over
00:48:44 cost management took priority over safety
00:48:45 safety rbkc did not decide to instigate a door closer installation program until march 2017 despite understanding from as early as 2009
00:48:56 as 2009 the criticality of door closes to the stay put policy in october 2015 a serious fire occurred at a detail in which the flat of origin's door
00:49:08 in which the flat of origin's door failed to close due to the lack of a door closer filling the lobby with hot gases and heavy smoke resulting in 24 fire survival calls and in that respect resonant of lachenal
00:49:22 and in that respect resonant of lachenal a deficiency notice had been issued prior to the fire identifying a failure to address the absence of self-closing devices thereafter enforcement notices were
00:49:33 thereafter enforcement notices were issued in 2015 and 2016 on adair and hazelwood towers including for failure to fit door closers and a deficiency notice was
00:49:44 door closers and a deficiency notice was issued on grenfell in november 2016 again for failure to fit door closers rbkc therefore had full knowledge of the extensive fire risks
00:49:55 extensive fire risks posed by the lack of door closes yet failed to commit to install closers across its estate until nearly two years after it had seen the serious consequences
00:50:06 consequences of this emission no door closer program was in place by the time of the file our bkc now accepts that an installation program
00:50:15 program should have been in place before then at the first of march 2017 meeting at which laura johnson gave approval for a door closer installation program
00:50:26 for a door closer installation program she pushed the installation of closers from a three to a five year program to quotes
00:50:31 quotes make the funding of the programme more manageable at that meeting she is recorded as agreeing to hold off recommending inspections programme at present
00:50:43 present not being convinced of the need for an expense inspection program which in our own words would have to be ongoing and therefore an additional expense to the housing revenue account indefinitely
00:50:54 revenue account indefinitely without any identifiable evidence that it impacted positively on the fire safety of residents this was a misguided and perverse
00:51:05 this was a misguided and perverse perspective given that two years earlier rbkc had a dare witness the best evidence of the devastation which ensues in fire if a door fails to close
00:51:18 fire if a door fails to close rbkc now accepts that guidance required regular inspections of door closers regardless of whether the decision not to instigate an inspection program
00:51:29 to instigate an inspection program emanated from rbkc or tmo both parties are equally at fault tmo had been warned by stokes in 2011
00:51:40 tmo had been warned by stokes in 2011 that the removal of door closes on the protected route was placing relevant persons at risk of death or serious injury in fire if a reminder of this were needed then
00:51:52 if a reminder of this were needed then the 2015 adair fire nevertheless even faced with prosecutions on a dare madison resisted the installation of door closers at all properties and instructed council to consider
00:52:04 and instructed council to consider whether they were only required were fundamental to the fire strategy and wondered how can we best transfer responsibility for maintenance of door closers
00:52:14 closers onto the tenant both rbkc and tmo failed to ensure the required means of escape from the disabled for the disabled despite rbkc having
00:52:25 for the disabled despite rbkc having originally been a trailblazer for accessible housing and being aware that inclusive design requires that buildings must cater for all
00:52:34 all as rbkc's claire wise said in 2010 specifying that disabled people should not live above ground floor is an unacceptable acknowledgement that existing fire
00:52:45 existing fire safety procedures are not inclusive tmo consulted with an access consultant and obtained a report addressing wheelchair access and door closers for
00:52:56 wheelchair access and door closers for those with limited upper body strength but ignored these considerations despite being made aware in 2017 that new doors at grenfell were too heavy for the elderly or
00:53:07 were too heavy for the elderly or disabled
00:53:08 disabled as tmo had no policy for identifying the needs of the disabled or processes for achieving
00:53:14 achieving the necessary protective measures there were no such measures in conclusion the failure of controls at every level requires a thorough examination of the
00:53:25 requires a thorough examination of the ambit of the order associated guidance and the competency requirements of fire risk assessors the order requires that buildings be safe and accessible to residents and
00:53:36 safe and accessible to residents and visitors
00:53:37 visitors and to that extent neuters the provisions of the building regulations which do not require re retrospective change nevertheless inquiry may wish to address the adequacy
00:53:49 inquiry may wish to address the adequacy of adb
00:53:51 of adb which albeit premised on inclusive design offers limited guidance on the topic
00:53:56 topic the multiple managerial and systems failures at grenfell which also include inadequately fire rated doors systems maintenance failures and inability to rapidly isolate the gas
00:54:09 and inability to rapidly isolate the gas supply
00:54:10 supply during the fire speak in favor of a safety case covering all aspects of a building's safety which could be audited by those with the relevant specialist knowledge and available to emergency services
00:54:23 and available to emergency services those are my submissions sir well thank you very much indeed miss barwise there's a lot for us to think about there
00:54:30 there and we're very grateful to you thank you very much
00:54:33 very much well now it's time for me to invite uh mr friedman queen's council to address us and make an opening statement on behalf of the same group of bereaved survivors
00:54:44 of the same group of bereaved survivors and residents so mr friedman are you in touch with us can you see me can you hear me i i can say i hope you can hear me good morning mr people yes certainly you can
00:54:55 morning mr people yes certainly you can and and good morning to you and miss estefan
00:54:58 estefan and uh mr apple well now we're running slightly ahead of time but there's nothing wrong with that and if you're ready to make your statement then please carry on i am
00:55:09 please carry on i am we address you especially now on behalf of two groups of batman the court participant first those who campaigned for a greater voice in agency in matters relating to their homes and
00:55:21 in matters relating to their homes and safety which they were knowingly denied second those who lost relatives whose disability or vulnerability meant that they could not escape without pre-planning and provision as was
00:55:33 pre-planning and provision as was foreseen before the fire but nothing was done we want to particularly draw your attention to the significance of the organizational and cultural context and to consider
00:55:46 and cultural context and to consider that part of the disaster which was the product of imbalance of power and disregard of the vulnerable the inquiry has reached the point where the causal role of these inequalities
00:55:58 the causal role of these inequalities cannot be ignored consistently with its terms of reference the missing fire safety measures were not just in the dangerously defective construction and lack of compliance but in defective
00:56:10 and lack of compliance but in defective political and administrative systems that no less significantly failed to prevent this unprecedented mass fatality the political and administrative context under rbkc in the
00:56:22 administrative context under rbkc in the tmo is dealt with in part two of our reconciliation we take it as a given that you will study and report on the legal contractual and regulatory structure that these organizations acted under but
00:56:35 that these organizations acted under but we want you to reflect on the way they behaved
00:56:38 behaved and why them so starting with the tma on paper it declared we keep residence at the center of everything we do it committed to giving the maximum
00:56:49 committed to giving the maximum involvement in areas like major improvement works in practice resident participatory participation was at most tokenistic or more often suppressed
00:57:00 suppressed whenever there was disagreement as a social housing manager the tmo was large and powerful it presided over nearly 10 000 households across some of the most expensive real
00:57:11 across some of the most expensive real estate in the world its size and monopoly had no equivalent across the united kingdom the tmo was not a democracy the number of members who voted for it to
00:57:22 of members who voted for it to continuing managing rbk's housing stock that each agm throughout the relevant period was on average never more than 10 percent of the households under its powers
00:57:34 powers the tmo had a single client and patron rbkc
00:57:38 rbkc it treated the council as the boss it's chairperson's word not mine if anything was sent to stage it was the wishes of the rbkc and you will see
00:57:49 will see this dynamic was exacerbated during the grenfell refurbishment project rbkc was the product of the leadership of the governing party that had led the borough for generations
00:58:01 that had led the borough for generations panel the wisdom of different approaches to social housing policy may be for other forums but you don't need to judge the politics in order to examine the causative effect
00:58:12 in order to examine the causative effect of values
00:58:13 of values and ideas if the inquiry finds that an ethos of indifference or hostility
00:58:20 hostility came to permeate the non-negotiable matters of fire safety as all the evidence suggests it did then it would surely say as much a key
00:58:31 say as much a key to the terrible handling of the grenfell refurbishment lies in its deeply ambivalent origins and motivations the project was from the outset a reluctant concession to vocal residents
00:58:43 reluctant concession to vocal residents who drew the politically inconvenient contrast between the expenditure on the school and sports centre
00:58:49 centre on their doorstep and the diffidation of their estate conceivably it only ever got the green light from rbkc because it was fought to mitigate
00:58:59 mitigate the perceived blight grenfell cast on the calc
00:59:03 the calc neighboring investment its cladding facade was sold as a combination of aesthetic and environmental progress which it seemed served to remove the need to ask about dangers and downside
00:59:16 need to ask about dangers and downside the investment needed to be sold to those who saw these units not as homes but as assets in the context of an identified 30 million pound funding shortfall in the ring fenced housing revenue
00:59:28 in the ring fenced housing revenue account
00:59:29 account grenfell towards considered one of rbkc's worst performing assets presumptively to be knocked down not refurbished lucrative mixed housing regeneration was
00:59:41 lucrative mixed housing regeneration was identified by rbkc as the solution to the funding shortfall the tmo believed with a degree of existential anxiety that it had to prove itself to rbkc as
00:59:54 that it had to prove itself to rbkc as able to deliver on such ambitious regeneration projects for fear of being replaced by someone else
01:00:00 else the tmo's desperation for in peter madison's words a seat at the table on such future projects
01:00:07 projects made it hypersensitive to the preferences of its single client meanwhile rbkc left the tmo in no doubt that its priorities were delivery on time and in budget
01:00:19 time and in budget and not resident satisfaction and safety that is all essential context for how the authorities behaved in the face of criticisms that were made
01:00:31 in the face of criticisms that were made by residents who campaigned to be treated as equals in planning procurement and scrutiny of the reverse they tried and failed to take on abk
01:00:42 they tried and failed to take on abk rbkc and the tmo with regard to the defects
01:00:45 defects and dangers in the works that they could see
01:00:48 see they did everything they could to compel transparency and accountability for the things that were not shown to them the defeat of the residents campaign for accountability is dealt with in part
01:01:00 accountability is dealt with in part three of the written submission it was achieved for a systematic and concerted denial of residence entitlements to be consulted informed and listened to
01:01:12 to be consulted informed and listened to modern administrative law established basic standards for any consultation exercise undertaken by a political body and provides a measure to judge rbkc and the tmo in this case
01:01:25 rbkc and the tmo in this case these standards serve the valuable valuable purposes of both improving decision making by properly testing proposals and avoiding the legitimate sense of injustice arising from denial of a fair
01:01:37 injustice arising from denial of a fair opportunity to influence an outcome to serve these purposes
01:01:42 purposes consultation must occur at a formative stage of relevant decision making provide sufficient time and information to enable intelligent response the decision maker must then conscientiously
01:01:54 decision maker must then conscientiously and with an open mind take into account what they are told schedule three of the modular management agreements between the tmo and rbkc
01:02:05 agreements between the tmo and rbkc and section 7 of the tmo's contracts regulations and guidance mandated that any major works project should include consultation involvement and oversight by affected residents
01:02:18 and oversight by affected residents the duties under scheduled room contains specific
01:02:21 specific prescriptive requirements for close involvement of a relevant relevant residence association that was entitled
01:02:28 entitled to establish a client review group to in effect
01:02:31 effect act as the client this gave it representation on the project team involvement in the decision to appoint consultants including architects and attendance of
01:02:42 including architects and attendance of site meetings to ensure quote that tenants concerns are addressed what is plain is that the tmo supported on this by the rbkc were entirely opposed to a resident's
01:02:54 were entirely opposed to a resident's association being permitted to scrutinize the grenfell works and we have asked you to look at how these residence rights under the foundation tmo documents were deliberately stonewalled and frustrated over a number of years
01:03:08 frustrated over a number of years the counterfactual exercise of just imagining
01:03:11 imagining a proper consultation on procurement in the works in this case is a powerful thing the architects studio in
01:03:19 studio in were appointed without tendering or establishing their experience and competency they have told you themselves in their evidence that they had that had a proper procurement exercise taking place they should not have got the job
01:03:31 they should not have got the job residents were simply told of their appointment after the event they immediately queried it but were brushed aside neither was there any meaningful consultation on the appointment of ryden
01:03:42 consultation on the appointment of ryden as the main contractor when the suggestion was raised internally with the tme
01:03:47 the tme tmo that it was necessary to involve residents in the march 2014 tender interviews the response was to ask if this was some kind of a joke that pretty much says it all you will
01:03:58 that pretty much says it all you will see that resident involvement was deliberately kept to the absolute minimum the evidence in module one and two has shown that there is an inextricable link between the appointment of
01:04:10 between the appointment of ryden and cuts that were made to the tender budget leading to the downgrade in cladding materials
01:04:17 materials sir the simple fact is that no properly informed resident given the opportunity to choose between rena bond acn
01:04:26 acn and the slightly more expensive zinc fr would ever have opted for the cheaper version without at least asking the question what are the downsides
01:04:36 downsides rainfall residents of course were never given the opportunity to ask as a matter of organizational culture the tmo had a fundamentally misconceived
01:04:47 the tmo had a fundamentally misconceived understanding of the purpose of resident engagement the primary aim was to achieve what it called
01:04:53 called buy-in and support for the project it countenanced a joint approach with rbkc to
01:04:59 to keep concerns in-house the overall outcome of this approach was that managers experts and contractors dominated to the exclusion of residents
01:05:10 of residents laypersons particularly residents were treated as having little or nothing of value to add therefore no right to comment on budget no right to ask about potential negative
01:05:21 no right to ask about potential negative consequences of substituting materials for reasons of costs no right to quit the credentials of a would-be architect or main contractor no rights no utility no dignity in relation
01:05:32 relation to what was being done to their own homes
01:05:36 homes but you will also see from the evidence that the tmo deliberately withheld important information with the bad faith intention to cover things up
01:05:47 things up on the 30th of october 2014 edward duffan requested meeting minutes of monthly project meetings between ryden the tmo studio e
01:05:59 between ryden the tmo studio e and others the application was disingenuously refused by blanket implication of commercial sensitivity this was not a one-off as we address in
01:06:10 this was not a one-off as we address in our written submissions it was part of a wider practice of deliberate misuse of the commercial confidentiality a practice dispute persisted in despite a complaint upheld by the tmos company
01:06:22 a complaint upheld by the tmos company sector team and tm and legal advice given to the tmo on the proper approach what was the real reason claire williams recorded it in terms in
01:06:33 claire williams recorded it in terms in respect of mr dahfan's october 2014 request it was to avoid critical scrutiny of problems she cited among other things problems of residual asbestos in flats
01:06:46 problems of residual asbestos in flats and what the tmo's own contractors described as the bombshell of residents remaining unprotected due to a non-functioning ventilation system despite an lfv deficiency notice
01:06:58 system despite an lfv deficiency notice claire williams advised that knowledge of these problems would quote cause mr dahan to raise more queries either on his blog or via further freedom of information
01:07:09 or via further freedom of information requests
01:07:11 requests panel would you say the october 2014 refusal to provide information is a genuine what if moment by the summer
01:07:20 summer of 2014 edward defan and francis o'connor
01:07:25 o'connor had posted a blog of a letter to ben dewis
01:07:28 dewis of the local lfb to say that quote residents of grenfell tower do not have any confidence that our building has been satisfactorily assessed to cope with the new
01:07:39 assessed to cope with the new improvement works the tmo sought and still seeks today to characterize the blog as alarmist but what was known to the tma but
01:07:50 but what was known to the tma but undisclosed to residents is by that time xover had produced three editions of a draft outline fire safety strategy
01:07:57 strategy for the refurbishment all of which expressly left the question of potential external fire spread to be answered in a future issue of the document
01:08:07 document no such issue ever came when gag then made the october request for information five consecutive monthly project meetings of task simon lawrence of
01:08:18 meetings of task simon lawrence of bryden
01:08:19 bryden was formally appointing a fire consultant but nothing was done on seeing those minutes residents could have insisted on a final report being prepared to complete what exoga had obviously
01:08:31 to complete what exoga had obviously left unfinished yet further also in the autumn of 2014 powell stokes produced a high priority action plan which was never disclosed to residents
01:08:42 which was never disclosed to residents or it seems the lfb this required ryden to detail the fire rating of the cladding and the fixings and obtain confirmation of the building control officer's acceptance
01:08:53 control officer's acceptance of this fixing system and the cladding used
01:08:56 used this too was not properly actioned during it all together the grenfell action group which had already queried whether the fire safety of the refurbishments had been properly assessed
01:09:08 been properly assessed was denied critical information demonstrating that it happened edward defan and the tmo could at least agree on one thing if the grenfell action group had found this out
01:09:19 this out of course they would have publicized it and of course they would have asked more questions
01:09:24 questions instead they and others who survived must live with the fact that they were denied the opportunity to keep themselves and their homes safe many of the bsr have shared experiences
01:09:36 many of the bsr have shared experiences in their inquiry statements of how the tmo rejected diminished and managed residents concerns and complaints as dr lane describes it resident
01:09:47 as dr lane describes it resident interventions were quote seen as a hurdle to get over a paperwork
01:09:51 paperwork problem to close out such that time and time again when the proper opportunity arose
01:09:56 arose the potential risk to life was not evaluated
01:10:00 evaluated one strand of this of this failure to this
01:10:03 this one strand of this failure to listen was an obsessive defensiveness towards edward dahan in august 2015 when he reported the door
01:10:15 in august 2015 when he reported the door to flat 136 on the 16th floor to be wide open
01:10:19 open because its self-closing device was broken
01:10:22 broken it seems that the tmo really did care more about dismissing his complaints than just fixing the actual door the door did not automatically close when hamid wabi
01:10:33 hamid wabi moved into flat one through sixteen of what 136 in february 2016. on the night of the fire the door still did not say itself closed causing smoke to fill the lobby joseph
01:10:44 causing smoke to fill the lobby joseph daniels and sheila died on that floor edward daphne survived only because he was dragged from the lobby by firefighter people coming down the stairs saw smoke
01:10:55 people coming down the stairs saw smoke filling their path most likely from floor 16 and we know that this is one of the reasons why they then went back upstairs to their death so criticism can be a good thing
01:11:08 so criticism can be a good thing and it certainly was at grenfell given the extent of the dangers that were being incubated by neglect for the tmo to withhold information because they did not like what their
01:11:19 because they did not like what their critics would do with it was unlawfully perverse and a patent abuse of power it is remarkable and telling that the tmo after everything
01:11:30 everything still seeks to perpetuate their criticisms of edward the farm in their opening submissions for this module that is indeed the advocacy of a non-functioning a
01:11:41 the advocacy of a non-functioning a moral organization that wasn't is more interested in its reputation than keeping people safe at the beginning of 2015 there was a building-wide anxiety about
01:11:54 there was a building-wide anxiety about the refurbishment and opposition to how residents were being treated rather than engaging with it the tmo did everything they could to deny it by march of that year residents across
01:12:05 by march of that year residents across the tower of all backgrounds ages and interests have come together they asked to be recognized as a more formal entity supported by a letter from the trade union unite
01:12:16 union unite there are poignant pictures of their meetings across that year that show a number of women and men who died in the fire as well as several survivors that the inquiry has come to know the response of robert black the ceo to
01:12:29 the response of robert black the ceo to that unite letter was to make clear his and the tmo's preference to not even nuke the group because he regarded him regarded it as a showcase for mr dahan
01:12:41 regarded it as a showcase for mr dahan in december 2015 the same group lodged a petition with rbkc the initiative involved councillor blakeman who had come to support its aims
01:12:51 aims the document was signed by 60 residents it called for urgent independent investigation by the rbkc housing
01:12:58 housing and property scrutiny committee of the conduct of the works and the treatment of residents of those 60 signatories 20 either died in the fire or were bereaved
01:13:09 bereaved again despite the number of signatures the evidence of residents views was still apparently dismissed within rbkc and the tmo are somehow representative
01:13:20 and the tmo are somehow representative unrepresentative due to it being organized or engineered by edward naffir among many other fallacies with this critique it discounted that the signatories genuinely believed what they had put
01:13:32 genuinely believed what they had put their name to or that there could be any value to what they were saying what followed before the spiritually committed was a further shameful lost opportunity rather than
01:13:44 shameful lost opportunity rather than commissioning an independent investigation the tmo council officers and the committee orchestrated the outcome to allow the tmo to investigate itself the tmo julie reported back despite
01:13:57 the tmo julie reported back despite council of lakeman's efforts to correct its errors and emissions in a document that was originally classified which dismissed residents concerns in their entirety without interviewing a single resident
01:14:09 without interviewing a single resident and instead glowingly commended itself and its contractor this was not edward daffan chatting his own path he was there alongside many
01:14:21 his own path he was there alongside many to name just a few that was willie thompson
01:14:23 thompson mariam el huari dennis murphy berkey and sheila who told me to peter madison in a meeting i am here because i am a vulnerable person
01:14:34 person there was leaseholder advocates like shah ahmed and tunde oadera residents with a pertinent professional background to see what was going wrong like david collins and there was judith
01:14:45 like david collins and there was judith blakeman
01:14:46 blakeman as an elected councillor and tmo board member who was increasingly bullied for supporting these people even though that was her job and the tmo was supposed to be resident-led
01:14:57 resident-led and resident-centered the tmo took her words at face value when it suited them and marginalized her when it didn't panel organizational exclusivity
01:15:09 panel organizational exclusivity and disregard for non-member input is a classically understood feature of human-made disasters and this is a textbook case the outsider is dismissed as a crank a
01:15:21 the outsider is dismissed as a crank a misfit
01:15:22 misfit or a manipulator recovers the stigmatization of the dissident creates a blind spot to the criticism being made they did this to ed the farm but don't
01:15:33 they did this to ed the farm but don't for a moment think that they didn't do it to shah ahmed david collins judith blakeman and anyone else
01:15:40 else who told them that they were wrong but to make matters worse there was an irresponsible assumption that anyone else was either being supinely led by these critics or otherwise
01:15:51 critics or otherwise content it ought to be obvious to anyone involved in social housing that residents may be reluctant to complain personally for a multitude of reasons
01:16:02 reasons including but in no way limited to immigration or housing status or experience as a member of minority of a minority race or ethnicity they must be entitled to rely on collective advocacy
01:16:14 collective advocacy rather than given the invidious choice of bearing the burden of speaking up alone or being silent or indeed silenced a functioning system of governments
01:16:26 of governments committed to listening without prejudice to its residents needed to be conscious and responsive to this in a way that the tmo and rbkc were deliberately not in the end even the most fearless of
01:16:38 in the end even the most fearless of residents
01:16:39 residents could only address on fire safely what they could see or were told about as a result of the deliberate withholding of information they were sometimes just able to communicate and encourage
01:16:51 communicate and encourage tacit awareness that they were unsafe from fire
01:16:55 from fire at grenfell again rather than respecting and
01:16:58 and acting on it founded it as it was on the intelligence of those who actually dwelt in the lived environment the tmo took advantage of the informational deficit it had created to repeatedly dismiss
01:17:11 it had created to repeatedly dismiss resident spears as unwarranted and unsubstantiated our final subject for today is the neglect of disabled and vulnerable residents that is set out in part five
01:17:22 residents that is set out in part five of our submission we note with respect that all bsr submissions have made this a centerpiece of their opening they and we have done so because although the
01:17:33 and we have done so because although the grenfell tower fire is many things it is surely a landmark act of discrimination against disabled and vulnerable the law
01:17:44 against disabled and vulnerable the law does not appear to be in significant dispute
01:17:47 dispute these were special categories of at-risk relevant
01:17:50 relevant persons to be identified planned and provided for by the responsible persons under the fire safety order 2005. the discharge of the fire safety
01:18:01 the discharge of the fire safety functions had to be informed both by the public sector equality duty in section 149 of the equality act and the internationally and domestically protected human rights to life
01:18:13 protected human rights to life and non-discrimination none of this happened as miss barwise has highlighted the tmo and rbkc now seek cover for the breaches of statutory duty in a
01:18:26 for the breaches of statutory duty in a few
01:18:26 few short passages in guidance developed by the sector and published by the local government association in 2011. colin todd is an expert witness in this
01:18:38 colin todd is an expert witness in this enquiry but his role in formulating and perpetrating the offending advice in the guide must itself be the subject of a scrutiny that advice states that there is usually
01:18:51 that advice states that there is usually nothing to be done for vulnerable residents in high-rise buildings operating a state book policy because it is unrealistic to make any special arrangements for them
01:19:03 any special arrangements for them no serious legal or moral defense a wholesale denial of fire safety to a class of residents especially in need of protection is offered in the guide or to this inquiry instead
01:19:17 or to this inquiry instead first a transparently false dichotomy between maintenance of a stay put strategy and simultaneous evacuation is floated to a reply outrageously that the status quo was in fact
01:19:29 that the status quo was in fact favorable to vulnerable persons as is plain to see the real issue is denial of planning and provision for evacuation when it is no longer safe to stay put
01:19:39 stay put next it's suggested that evacuation should all being well with compartmentation rarely be required this is simply not an acceptable answer to the situation
01:19:50 acceptable answer to the situation when all is not well which even the lga guide contemplates that is why the fire safety order so clearly imposes non-delegable duties requiring planning
01:20:02 non-delegable duties requiring planning and provision for all residents not just those with additional without additional needs as it happens the three other inquiry experts dr lane
01:20:13 experts dr lane professor galea and professor torreira strongly disagree with mr todd regarding the limited risk of compartmentation breach
01:20:20 breach in high-rise buildings as a class colin todd
01:20:24 todd and those in the sector and government who agree with it have demonstrated themselves unable or unwilling to stand back and reflect on the status quiet remarkably in the
01:20:35 on the status quiet remarkably in the immediate aftermath of the phase one peak recommendation mr todd and industry rushed out new draft national guidance in the form of past 79 2020
01:20:46 in the form of past 79 2020 doubling down on the do-nothing approach and deliberately deleting positive provision for disabled and vulnerable residents found in their predecessor edition the bsi
01:20:57 bsi has recently seen the wisdom of withdrawing past 79 2020 and reconsidering the issue and so too
01:21:05 too the home office despite initially being lobbied to contemplated departure from the inquiries phase one peak recommendation by a sector special interest group submission that mr todd had again contributed to
01:21:19 that mr todd had again contributed to a major fault of the dogmatic sector stance
01:21:22 stance is its lack of openness to existing and new ways
01:21:26 new ways to improve the safety of disabled and vulnerable residents it pays no regard to the idea that disabled residents could be important experts in the pre-planning of their own evacuation
01:21:37 pre-planning of their own evacuation that responsible persons could meet and learn from there and it shuts its eyes to available best practice
01:21:44 practice on inclusive evacuation planning across the country in the world it also raises troubling questions as to the underlying motivations budgetary concerns can no longer be
01:21:55 budgetary concerns can no longer be allowed to uncritically trample matter as important as equal enjoyment of safety
01:22:01 safety in the event of fire ultimately the view that nothing can be done as well as being unevidenced and wrong sanctioning out sanctions and outcomes
01:22:12 sanctions and outcomes even if that is not its aim that treats disabled residents in high rise buildings
01:22:17 buildings as if their lives don't matter i want to finish if i may by reflecting that there is a link between the closed nature of discussion
01:22:28 nature of discussion between government managers and specialists and at this national level and what went on with the rbkc tmo and its contractors at grenfell no one was particularly interested in
01:22:40 no one was particularly interested in involving ordinary people quite the opposite the results are profoundly anti-democratic and disrespectful grenfell residents had no part in the choice of their
01:22:51 no part in the choice of their architect contractor design amendments or access to fire risk documents nor any chance to be informed and cooperate in the pre-design of their own evacuation
01:23:02 evacuation made with daphne's statement to this inquiry eloquently tells how this tragedy played out in three acts before during and after the fire each of those acts involved a markedly
01:23:14 each of those acts involved a markedly negative view about the wisdom and resilience of people when they come together as groups
01:23:20 groups before the tmo and rbkc were desperate not to recognize collective community representations during
01:23:27 during the firefighters thought that mass evacuation would only cause panic and injury
01:23:32 injury after the authorities feared that there would be uprising or kensington street in fact each part of the inquiry's evidence
01:23:41 evidence indicates the possibilities when ordinary people come together they speak truth to power prompt new ways of seeing old problems save themselves and others as the real first responders in emergency
01:23:54 the real first responders in emergency and create the first and most enduring forms of support in recovery just as culture values and ideas were among the key causes of the fire
01:24:05 causes of the fire a more cooperative and co-productive approach
01:24:08 approach involving dialogue with and and participation of residents must become a fundamental aspect of fire safety in the future but to make a firm foundation for such a
01:24:19 but to make a firm foundation for such a program
01:24:20 program the inquiry needs first to clearly and unequivocally identify the root cause of this disaster in the disempowerment and unequal treatment of residents
01:24:32 treatment of residents people with less influence money and expertise
01:24:35 expertise were essentially rolled over and the various tools of human rights helping safety and public protests were not sufficient to save them
01:24:46 not sufficient to save them thank you sir those are our submissions well thank you very much indeed mr friedman a very powerful statement which will give us a lot of food for thought thank you very much
01:24:57 food for thought thank you very much um we've got to the point in the morning at which i think we should take a short break uh we're running slightly ahead of ourselves which is always welcome so um what i'm going to
01:25:09 always welcome so um what i'm going to say is we'll break now we'll resume at 20 to 12 provided mr mansfield who is due to speak next is ready at 20 to 12 if he's not that
01:25:20 is ready at 20 to 12 if he's not that doesn't matter he'll take him at the time advertised which is quarter to 12 but so we may resume at 20 to 12 all being well
01:25:31 well and we'll see you then
01:40:08 welcome back everyone i'm now going to invite
01:40:11 invite uh mr mansfield queen's council to address
01:40:15 address the panel on behalf of the other group of bereaved survivors and residents mr mansfield good morning can i just check that you can see me and hear me well uh very much there say yes thank
01:40:27 well uh very much there say yes thank you very good well good morning it's good to see you um and well when you're ready i think we're ready to uh kick off yes thank you sir well sir and thoria estefan and ali
01:40:40 well sir and thoria estefan and ali akbar your co-panelists uh we are much obliged for this opportunity to open for team two i've listened very carefully as i'm sure
01:40:52 carefully as i'm sure everyone has to what has already been said and i will try and avoid repeating the detail of the two previous uh submissions to you which with which
01:41:03 uh submissions to you which with which we agree
01:41:04 we agree so there would be little point in duplication in addition to that of course we have already submitted questions as well as a written opening so again
01:41:15 a written opening so again no purpose would be served in repeating all of that but what i would like to do is just to pause for a moment before using a rather different approach in the
01:41:27 using a rather different approach in the hope of
01:41:28 hope of illustrating in a sense what you heard by way of
01:41:32 by way of uh criticism of the regulations of the people
01:41:36 people who are supposed to implement the regulations of attitudes and so on before dealing with a particular approach and perspective is to bring it to life through the eyes
01:41:48 is to bring it to life through the eyes of the families i'm going to avoid using the term beer cells if you'll forgive me but the families
01:41:57 families and the voices of the families because the first reflective moment because this is a historic moment
01:42:08 moment because this is a historic moment in this
01:42:08 in this inquiry when after so long we return to the families themselves and what they have to say
01:42:20 and what one has to bear in mind i would i would ask everyone to bear in mind is and the reason why their voices at this moment at this
01:42:31 their voices at this moment at this juncture are so important is firstly you have to have to remember it's easy to just override it and forget because so much else is happening as we speak that
01:42:42 as we speak that they and particularly one of the people i want to mention in more detail ahmed had suffered a great deal before this fire
01:42:54 fire they had suffered and somebody's already mentioned it this morning 20 years 20 years of neglect
01:43:04 and the neglect isn't just concerned with fire safety
01:43:12 and if i make i don't i just want to illustrate it it's in one sense it's minor but it really tells you everything about what's been going on there it's not fire related it didn't cause
01:43:24 it's not fire related it didn't cause the fire
01:43:25 the fire it didn't cause the death but it tells you everything in one short cameo of what had been going on for years before this fire
01:43:37 before this fire a gentleman whose name i will not mention
01:43:40 mention who lived on floor 15 said one of the upper floors
01:43:46 he suffered from bowel cancer
01:43:51 and that was known
01:43:56 for six months he had a flat in which there was no functioning lavatory
01:44:05 think about that for this person what did
01:44:08 did this gentleman have to do to get something done
01:44:14 and i think stephanie barwise said staggering lack of concern it's worse than that he that is this individual
01:44:25 he that is this individual had to go to north kensington law center in order to get legal help and also get his physician to intervene in order to have a working laboratory
01:44:36 in order to have a working laboratory and then we wonder why the tower suffered in the way that he did
01:44:41 he did because that's the suffering that's the kind of suffering it indicates an attitude of mind that happened
01:44:48 happened over that 20-year period but then on top of that
01:44:52 of that these uh residents and families suffered the fire itself and you've heard something of that and i want to in a very short while just reflect on a small passage of that which
01:45:04 reflect on a small passage of that which illustrates what's happened but they suffer the fire and then afterwards of course they go through
01:45:13 a terrible period in which there are more housing problems and difficulties for them
01:45:19 for them just in daily living and then on top of that comes the pandemic and the difficulties of the hearings and not being able to attend and of
01:45:31 and not being able to attend and of course
01:45:32 course modules one and two did not include the voices of the families although they have plenty to say about
01:45:43 although they have plenty to say about the issues in modules one and two instead they had to sit at home usually and watch and i hope this is not an understatement
01:45:55 and i hope this is not an understatement or even an overstatement they had to watch a parade of arrogance there may be one pandemic outside the hearing there's another one
01:46:07 outside the hearing there's another one inside it
01:46:08 inside it and it's the pandemic of lies of manipulation of deceit of jocularity of pride in what they're joking about
01:46:21 and one has to ask obviously how that has come about and we are approaching a different stage it's one thing to work out how the fire
01:46:34 it's one thing to work out how the fire was caused and how the deaths were caused
01:46:38 caused the bigger question is why did this happen and so therefore the one way of encapsulating
01:46:49 one way of encapsulating what has happened over these 20 years and it's epitomized in the construction industry and the race to the bottom of the description you've heard before
01:47:00 the description you've heard before is what we now have and i'm going to characterize it if i may in this way but what the council the royal borough of kensington created was a chronic culture
01:47:14 was a chronic culture of neglect of that there can be little doubt of indifference and discrimination underpinned
01:47:25 and discrimination underpinned by as you've already heard a theme of dishonesty in the sense of not revealing information how is it that the construction industry
01:47:37 how is it that the construction industry in a sense and the authorities you're about to hear are conjoined in one continuum this bigger question of
01:47:49 bigger question of what is lying behind the construction industries approach and the local authorities approach and before moving into some of the
01:48:00 and before moving into some of the illustrative examples there is another reflection which may have struck you this morning if not before probably before well before
01:48:11 before and that is this
01:48:14 the staggering lack of concern leads one to believe and leave one to examine what we've put in our written submissions
01:48:25 submissions that whatever happens in this inquiry it is important that any recommendations and it's important that any themes that come out
01:48:35 come out are enacted and implemented but as you have seen
01:48:39 have seen if those in a position of authority whether it's in the construction industry or the local authority are of a particular mindset
01:48:52 are of a particular mindset it doesn't matter what the regulations are it doesn't matter what the statutory duties are because at the end of the day they think they're immune they think
01:49:05 they're immune they think they can laugh about it they think as they did in the construction industry well that's what we do lie is that the society that has been created
01:49:15 created over the last 10 20 years and we say there's a risk of that continuing unless there's a real attempt to change the mindset so that whatever
01:49:27 to change the mindset so that whatever one says
01:49:27 one says ought to happen and even if you set it in law
01:49:31 in law you ensure that it is enforced and people are made accountable
01:49:41 so those are the reflections before i even begin the examination because what i would like to do
01:49:50 is to go back to the night in question just for a moment and i want to as it were bring to life all those deficiencies and defaults you've heard
01:50:02 deficiencies and defaults you've heard about
01:50:03 about in the written submissions as well as the spoken
01:50:08 today and you were there for the pen portraits and you've been to the tower may i i don't ask for answers it's not a
01:50:21 may i i don't ask for answers it's not a rhetorical question that your co-panelists if they haven't watched the pen
01:50:26 pen portraits would they be kind enough to do so
01:50:29 do so because it brings to life the lives of those who died and the eclectic
01:50:37 eclectic quality of the lives that died the diversity already mentioned of those who died
01:50:45 who died in this remarkable i've called it the vertical village which has been destroyed although the people who live on still have it in their hearts
01:50:58 but the uh pen portraits are one thing and again to your co-panelists thoria and stefan and aliak or if you haven't been to the tower
01:51:10 haven't been to the tower may i ask that you do visit the tower provided it's safe obviously i'm not sure what the present situation is and you may have already visited it it's important in order to understand
01:51:21 it's important in order to understand just how
01:51:22 just how serious the uh not not just the happening on the night but what went before it as well and then it's put in a context
01:51:33 as well and then it's put in a context once you've walked up that stairwell you've walked up the staircase you've seen
01:51:39 seen the conditions and just the space conditions it then takes on a new dimension so i'm going to if i may just uh read a
01:51:50 so i'm going to if i may just uh read a portion it's only a small portion and i'll make it clear at the end if it doesn't become chair straight away about whom i'm speaking in relation to this
01:52:01 this and it will bear upon what we say are the important findings in this particular module
01:52:08 on the tuesday evening before the fire so that's the 13th of june it was a normal night for me
01:52:18 we went to bed around 11 30 but i couldn't really sleep i must have fallen asleep but it wasn't a very deep sleep i think our bedroom
01:52:29 a very deep sleep i think our bedroom door was slightly open that night because
01:52:31 because it was hot my kitchen window was open too i'm going to miss certain sections which don't bear upon the immediate points i want to make
01:52:43 want to make i got up i didn't see any smoke until i went into the kitchen as soon as i got into the kitchen and looked down out of the window
01:52:54 and looked down out of the window i saw a big fireball coming up from the outside of the building it was the color
01:53:03 the color of a of of burning sunset i initially thought it must have been a fire in the flat below the kitchen window
01:53:15 in the flat below the kitchen window then exploded inwards i was lucky i wasn't close to the window i dialed 999 on the house phone from the living room however before completing the call and speaking to anybody
01:53:26 speaking to anybody i threw the handset down and decided to get out
01:53:30 get out until recently i believed i had not been completed the call however the police have informed me that i did in fact complete the call though i didn't speak to anyone before i threw the handset down
01:53:43 threw the handset down and this is important for this section i'm glad i didn't speak to the operator as i might have been told to stay put well that's a point i want
01:53:54 to stay put well that's a point i want to come back to in fact what he didn't realize was that what he then did was overheard by the operator my wife and i banged on the door of flat
01:54:05 my wife and i banged on the door of flat 155 and shouted fire fire fire i then went to one five four the man there opened the door a little bit i told him to get out
01:54:17 bit i told him to get out because there was a fire then i banged on 153
01:54:21 on 153 but i can't remember if there was an answer then i banged on one five two i think someone answered all that i can't remember clearly then i banged on one five one a lady with a walking frame
01:54:34 one a lady with a walking frame answered i told her there was a fire to get out
01:54:39 get out there is a smoke alarm another point you may wish to pick up on in this in the lift lobby but it wasn't ringing
01:54:47 ringing otherwise the other flats would have heard it
01:54:50 heard it and i had i wouldn't have had to tell them there was a there was a fire it goes on of course and it it may be uh
01:55:01 clear about who it is he goes back to his flat to get his mobile
01:55:09 mobile phone he tried to go back but when he opened the door he saw thick white black mixed smoke smell smoke something like burning i don't know what exactly
01:55:20 don't know what exactly i didn't feel the heat coming i shut the door straight away then i thought we have to get out it was fight or flight through my years of
01:55:29 of fighting for the health and safety of the building
01:55:35 i had the instinct to know the building was not safe and that it was a ticking time bomb now the person at the root of this and
01:55:46 now the person at the root of this and his wife said is shah ahmed now i i'm going to use his if unlike the prism of what happened to him in order to
01:55:59 of what happened to him in order to illustrate just how serious this chronic culture fostered by the local council had been because he knew what he was in for
01:56:12 because he knew what he was in for if he stayed put not only did he know he had very clearly signposted what was wrong with the block
01:56:26 so in a sense he's an expert and the families are experts in terms of what they knew we have it in the building sector the
01:56:37 we have it in the building sector the construction sector whereby companies knew full well some of them that they were providing combustible materials but they went
01:56:48 combustible materials but they went ahead why
01:56:49 ahead why profit and in this area we have a very similar situation the similar situation here is where they are being told that is the authority
01:57:02 are being told that is the authority what is wrong and what is going to happen but they do nothing that is why we say it's a chronic culture all the way through uh whether it's a lavatory or anything
01:57:14 uh whether it's a lavatory or anything else this is where essentially there's discrimination of a class of people and i'll come back to that as well
01:57:25 and i'll come back to that as well just pausing again on that particular chronicle if i may put it that way so that it can be uh seen in another context
01:57:38 uh seen in another context he that is shah ahmed lived in flat 156 which is why i've mentioned all the other flats he went to on the 18th floor between
01:57:49 on the 18th floor between and this is in your phase one report between
01:57:53 between twenty past one so we're dealing with a situation obviously in the middle of the night
01:57:59 night and half past one that's ten minutes the fire had it enveloped and anyone i'm not asking the scenes to be shown and that's why it's so important to keep
01:58:10 and that's why it's so important to keep going back to what happened here the fire enveloped all the sixes by which i mean all the flats ending in six who are on one above another in the tower between floors 10
01:58:24 in the tower between floors 10 and 23.
01:58:28 and in fact his telephone call to the operator was at 127.56 and he exited with his wife at 1 31 so he got out just in time
01:58:43 at 1 31 so he got out just in time but without again going through it it would take too long and it would take the number of days it did at the first at the start and in phase one you then have the picture of what
01:58:56 you then have the picture of what happened to everybody else some survived and a large number didn't but what were they facing the ones who were not able to get out in the way that he did
01:59:08 he did they were facing as you will recall a situation in which the stairwell was filled with increasing amount of black acrid
01:59:20 amount of black acrid smoke with the difficulty of walking down the stairs in the night badly lit
01:59:28 badly lit badly signed in fact refurbishment what have they done nothing absolutely nothing to the means of escape it was still in the same condition and this again
01:59:41 in the same condition and this again tells you how bad the neglect had been and there are those who are making phone calls
01:59:48 calls who are being told to stay put and others the operator says well just open the door you just got to go you've got to go and they're talked down others can't do it others are left to
01:59:59 others can't do it others are left to die
02:00:01 die that's the chronic situation that has been created on the night and those doors that he tapped on
02:00:11 tapped on two of them are in it is significant because they tie in with what we say is a dereliction of duty here
02:00:19 duty here now well before you in flat one five four where the door opened there was in fact just one man living
02:00:32 he died he had a mobility problem that was known
02:00:38 was known he was disabled he didn't die in his flat he managed to go up and you will recall a number did do that in the hope that
02:00:49 a number did do that in the hope that there might be a rescue from above so he unfortunately mainly because of course no one had thought about how's he going to get out
02:01:01 thought about how's he going to get out then
02:01:04 too much trouble to think about that one has to
02:01:07 has to just pause for a minute what are we saying it's necessary to have protocols and regulations before you begin to think about who's living in the block you own
02:01:16 you own is that what is spent well if that's what it takes that's what it takes but the
02:01:20 the problem here is whether the caring society has as it were left certain people at the door
02:01:28 door including the authorities but he he died in fact six occupants on this floor died
02:01:39 on this floor died five of them he's one of them went to floor
02:01:43 floor 23 above flat 151 where he tapped and two sisters they were i'm not going to name them all the time one with the frame
02:01:57 all the time one with the frame those two sisters they went up as well to floor 23 and they died
02:02:07 and and just reflecting here on the total situation for a moment out of the 120 flats how many flats contained people who were disabled
02:02:20 contained people who were disabled in various definitions dealing with age either old or young or mental difficulties physical difficulties reading difficulties hearing difficulties seeing difficulties
02:02:32 hearing difficulties seeing difficulties 52 out of 120 flats and i won't obviously either on screen or off at the moment deal with there's a schedule that you have we i think submitted it
02:02:44 have we i think submitted it with our uh written opening which indicates
02:02:48 indicates the number of individuals who had an impairment uh this you would think it is common sense
02:02:56 sense you would want as a caring authority to ensure
02:03:00 ensure that you look after and provide safety why do we have to write it out well apparently we do but there is and it hasn't been mentioned extensively but i just want to mention it's in our written submission so i don't
02:03:11 our written submission so i don't develop it there's an obligation upon the inquiry itself under article 2 and article 14 in relation of
02:03:23 in relation of in relation to human rights the protection of life and the prevention of discrimination and that you make inquiries and you investigate the extent to which
02:03:34 investigate the extent to which besides the protected characteristics here whether there is a racial characteristic which enters this arena because you have to ask why for so long
02:03:46 for so long a whole diverse community have been ignored basically that is a question that has to be out they have a duty again under the statutory duty 2010 the
02:03:57 again under the statutory duty 2010 the equality act a public sector equality duty
02:04:01 duty and and that must not be shirked it can't be
02:04:05 can't be delegated it can't it's not negotiable uh and we say they must have known about that but were not 2010 it's a an interesting year
02:04:17 not 2010 it's a an interesting year happens to coincide with some occurrences i'm going to come to in a moment 2010. so that's a very important one of many statutes we've put them all
02:04:28 one of many statutes we've put them all in our written submissions but that perhaps rises to the surface so that and we give other examples of the disabled who died because there was no provision
02:04:41 no provision and i'm i'm citing to move on in one moment to um the experiences of shah ahmed but before i do
02:04:52 i do it's uh it was part of his experience as well
02:04:57 well i'm going to go back from the night itself in other words we're moving back from the 14th through the 13th there there is an irony here
02:05:09 here that he might have reflected upon at some point on the 10th of june it's only four days before
02:05:18 before there were a series of visits
02:05:22 fire home fire safety visits four firemen from the north kensington white watch
02:05:29 watch visited a number of flats not all of them but a number
02:05:38 and 25 altogether they visited now the object
02:05:41 object usually have a home fire safety visit two prime ones so obviously make sure the alarms are working and also if there are people who have
02:05:52 if there are people who have particular vulnerabilities of the kind i've already described they should be getting advice
02:06:01 now of the 25 flats visited 15 of those flats
02:06:07 gave rise to 32 people dying on the night and 20 of those 32 were vulnerable in the various categories
02:06:18 categories and one of the flats that he they went they did go to interestingly they didn't go to the two i've mentioned uh next to shah ahmed uh
02:06:30 uh next to shah ahmed uh that's one five four and one by one they didn't go there but they did go to his what's important about the visit to him and you may remember that there was a a witness in phase one
02:06:42 a witness in phase one who remembered shah ahmed
02:06:46 and it's interesting because shah ahmed's name is not well known in fact
02:06:54 and i want to come to him in a moment as an individual representing essentially so many people in the block but the point he wanted to make
02:07:06 but the point he wanted to make a point he was utterly correct in making but the fire officer who spoke to him said i'm not an expert i can't help you about that you you persist with your inquiries with the
02:07:18 persist with your inquiries with the council well that advice was certainly right because what he was talking about were the pipes the gas pipes that had been inserted
02:07:29 the gas pipes that had been inserted without
02:07:30 without consultation up the only means of escape a protected means of escape and then inserted into flats and if one morning you suddenly saw this
02:07:43 and if one morning you suddenly saw this kind of work happening where you lived i think you would be worried highly dangerous inflammable gas inserted in this way of course where should it have been outside
02:07:55 should it have been outside it couldn't be outside they were more concerned with flammable cladding of course so they couldn't put it outside however i want to return to to that but
02:08:06 however i want to return to to that but that's just in passing and also before we get to
02:08:09 we get to a next major event i want to mention to you
02:08:14 you going back in time it's only a few days just before the 10th
02:08:20 vents vents is a key element of what happened on the night and why it happened on the night as well vents not working between the
02:08:31 as well vents not working between the 6th and the 8th of june there's plenty of documentation to indicate it was known that the automatic opening vents were not operating
02:08:42 operating a few days before the fire one of the reasons had been serviced the service record for that indicates
02:08:54 the service record for that indicates that they should be every six months but it hadn't happened and of course they hadn't been tested and of course the whole of the system hadn't been tested or or
02:09:05 hadn't been tested or or as an integral whole properly assessed so one has here therefore the fire fire visits knowledge that the vents are not working but then we get
02:09:17 not working but then we get to what i call a key moment now i'm mentioning uh ahmed himself but he he would want it known that what he
02:09:27 he says he said on behalf of residents as a whole
02:09:34 and i'm doing this in particular with particular emphasis because as you will be aware
02:09:42 he's taken an extraordinarily responsible approach
02:09:48 to the block to the authority because he is concerned and cares about the environment in which he lives it's not just about
02:09:59 not just about fire it is also about general health welfare and the environment as a whole and when he made submissions they were always detailed they were always
02:10:10 always detailed they were always reasoned
02:10:11 reasoned and admittedly he put them in more than once because of course he wasn't actually being listened to anyway until he got to the end the only reason things happened to move
02:10:22 the only reason things happened to move just before the fire as we now know as barbara lane has indicated him is because he was making a fuss he never gave up he persisted it's taken
02:10:34 he never gave up he persisted it's taken its toll
02:10:35 its toll which is why we we say this detail it's taken his toll he's now no longer able to give live evidence that's what he wanted to do he wanted to
02:10:46 do he wanted to bring it to life himself but he can't do that
02:10:51 that but he has as you know contributed three statements one in phase one two in phase two
02:10:58 two one very very recently in answer to a large number of extremely pertinent questions that uh were posed to him and he's produced a
02:11:09 were posed to him and he's produced a dossier if i can call it that running to several volumes in my case uh printed off to four volumes of documentation he's assembled to assist the inquiry
02:11:21 to assist the inquiry so it's not only his assiduous approach and responsible approach he's probably one of the few who've experienced it almost from the beginning
02:11:33 experienced it almost from the beginning 25 years he's been there with his wife his son was born there and he established the association of leaseholders in 2010 that very year
02:11:46 leaseholders in 2010 that very year and i will have to re return to that in a moment but what happened just before
02:11:53 before the date i'd got to the date being the revelation about the fence on the 6th and 8th of june probably discovered before that at the end of may he did something well
02:12:07 he did something well not remarkable in one sense but it just demonstrates how far as you've already heard in the previous
02:12:15 previous two openings how far the neglect the inner sense the dismissive nature has got
02:12:27 the dismissive nature has got but what he does at the end of may so it's
02:12:31 it's two weeks to go before the fire he puts together a bundle of it's all there for you to see a bundle of documents
02:12:42 of documents indicating his worries as before because they've been surges and other things he's had to complain about he doesn't go on his own he doesn't only do the leaseholders of which there are fifteen flats
02:12:55 which there are fifteen flats uh and three are uh housing associations he's not just doing it for them he goes he knocks on every door that he can within the block
02:13:08 within the block and he achieves over 90 percent each time he does it over 90 of the occupants support what he's doing
02:13:15 doing and know him well and respect him well for what he's doing the voice of the people unheard unheeded heard maybe but certainly unheeded so he
02:13:28 heard maybe but certainly unheeded so he puts together a dossier it isn't just about the fire the possibility of fire safety of course he's got that point he has other concerns which relate back to issues i've already
02:13:41 which relate back to issues i've already mentioned
02:13:42 mentioned so that go over the years that the power surges
02:13:46 surges that happened in 2013 and of course the fire that did happen in 2010 the year he formed the association so he takes the dossier in person he
02:13:58 so he takes the dossier in person he doesn't trust sending it because he's tried all that you will see on his emails he he copies in pretty well everybody you can think of
02:14:09 you can think of so judith blakeman the local councillor essentially lives nearby has a surgery nearby knows well what's going on so that's a familiar name and will become more familiar
02:14:20 become more familiar but he doesn't restrict it to her he goes to the mp he goes to ministers and what he's been forced to do at this late stage because he believes they're not doing anything all he was wanting well i say
02:14:32 anything all he was wanting well i say all
02:14:32 all he wanted reassurance from the council that they were getting on with the job because he knew from reports he'd got in relation to the 2010 fire they
02:14:44 in relation to the 2010 fire they weren't telling the truth in 2010 i'll come to in one second there was a fire which he was unfor
02:14:55 there was a fire which he was unfor unfortunately not himself present but his wife was but he knew that they eventually conceded on that fire that in fact he had suffered but it took a
02:15:07 in fact he had suffered but it took a legal action then to get them to recognize so he he felt from the fire brigade report which clearly indicated then vents were a problem
02:15:16 a problem he wouldn't trust what the council were palming him off with so that he had decided to take legal action and go to the housing ombudsman at the end of may
02:15:27 of may he was preparing essentially a brief he'd employed lawyers to go and do this and of course laura johnson sitting in the background saying oh well if that's you know let them do whatever they want
02:15:38 you know let them do whatever they want kind of thing essentially we're not going to do or they started to do something but in fact it wasn't without this prompting that we say the boxing in started
02:15:50 that we say the boxing in started now the the pro it's a simple point if you put
02:15:54 you put pipes through a communal stairway as i've already indicated that into flats there are all sorts of risks if you're going to box it in you've got to ventilate it properly you're breaking the seal of compartmentation
02:16:05 the seal of compartmentation possibly breaking the seal you've got a highly inflammable situation should a fire break out on the stairs or anywhere else for that matter and you will recall that it took 18 hours
02:16:16 hours to find where to switch it all off and when they did what did they say fire went out like a light well it probably mainly gone out by then anyway but in any event this is why this was so important and he was quite right
02:16:28 was so important and he was quite right even though it may not have caused this fire
02:16:31 fire even though it may not itself have contributed to the smoke and the deaths nevertheless as he's now supported by the opinions expert
02:16:44 supported by the opinions expert opinions of barbara lane then he undoubtedly can can rest that he has done a very fine job in what he did
02:16:54 and this was because in addition would the council meet him to deal with this and and default and others because he wasn't alone he was doing it with others no wouldn't meet wouldn't give him of
02:17:07 no wouldn't meet wouldn't give him of the what he wanted was the assurance of a fire
02:17:10 a fire safety certificate to show that what the national grid were doing was all right as the fireman who come to his flat said well continue continue pressing well he did continue pressing
02:17:21 pressing nothing was forthcoming to indicate what assessments they'd had so he had no idea what they were doing so he had to do it almost in a vacuum
02:17:30 a vacuum but and the ultimate test in a sense was he
02:17:35 he asked the council well how about an independent said this from the beginning how about an independent investigation how about
02:17:44 how about an individual independent assessor somebody who's qualified to do the job
02:17:52 he asked for funding by the council for somebody independent not somebody commissioned by the council not somebody paid for by the council somebody that was instructed externally
02:18:04 somebody that was instructed externally they wouldn't countenance it they wouldn't allow him any funding so he decided in the end at this late stage he'd have to fund it himself or try and get others within the block to help fund
02:18:15 to help fund so these legitimate concerns that took him to the town hall and other places on the 30th to ensure everybody
02:18:24 everybody had a bundle of fire risk and the rest sitting on their desk in the hope that it might
02:18:30 it might make a difference
02:18:34 and that in a sense brings me conveniently to what is possibly and i hope again not overrating it too much the
02:18:47 too much the one of the most um compelling documents in the case
02:18:55 as a whole i've asked for this one to be put up because i think otherwise because mr shah is not going to be able to give evidence himself his evidence no doubt will be read at some stage
02:19:08 no doubt will be read at some stage certain items can get submerged and perhaps forgotten or they don't assume the importance that they deserve but this and i have given the references
02:19:19 this and i have given the references which i will give now it is a letter that he wrote in 2010 to the newly appointed chief executive
02:19:30 to the newly appointed chief executive uh mr robert black now i'll give the reference it's tmo one zero zero three seven four three nine underscore zero zero
02:19:42 three nine underscore zero zero one so if that first page could come up please
02:19:46 please and if it could be enlarged it might be possible for me to read it off the screen but i've got a hard copy the first page it's from the grenfell tower leaseholder association we've been
02:19:57 tower leaseholder association we've been set up earlier in the year it was earlier in the year of 2010 that uh he suffered the fire it's uh that same year that i've already
02:20:09 uh that same year that i've already mentioned in another context but it is a year of ensuring that he wrote
02:20:16 wrote to everybody who really mattered or should have mattered and there they are listed so this isn't something where he he keeps it to himself or he only does
02:20:27 he keeps it to himself or he only does it in particular and he's having to do all this
02:20:30 all this as he did on the 30th of may because the complaints are system was outdated cumbersome not simple and was used to shut them off that's the phrase lock them out
02:20:42 that's the phrase lock them out essentially we can reduce this class to non-existence by having a complaints procedure
02:20:52 procedure which is why he used the members request route via judas blakeman who sometimes managed to achieve a little more now the letter itself i'm only going to read certain passages
02:21:03 i'm only going to read certain passages not the whole the letter is extensive and goes over uh i think it's eight pages yes eight pages so and it has signatures other than his
02:21:14 so and it has signatures other than his own
02:21:14 own because he got support and this is what he writes we received a written response dated the 20th of august 2010 from mr daniel wood the head of the home ownership however
02:21:25 the head of the home ownership however we were expecting a direct response either from you or mr anthony parks we've chosen to respond to you directly instead of mr wood
02:21:34 wood for the simple fact you originally made the commitment to look into our issues and concerns
02:21:43 mr wood in effect refuted and flatly ignored our long-suffering and serious issues
02:21:49 issues this demonstrates as head of home ownership he's not aware of the reality of the situation that grenfell tower is out of touch as to what's going on it seems he has based his response on what
02:22:00 he has based his response on what appears to be common answers if we simply take the issue of block aesthetics it's clear to see how grenfell tower has been neglected for decades the letter we received
02:22:11 for decades the letter we received indicates
02:22:12 indicates that the tmo does not adhere to the promise of being tenant-led organization may we pause the tmo was never tenant led
02:22:23 the tmo was never tenant led and in fact uh was quite the reverse if we could just turn over the page very quickly to zero zero zero two at the top
02:22:35 second point he wants to make we will argue that the recent fire at grenfell tower has raised so many health and safety issues with the building that it demands an independent investigation and inquiry
02:22:47 independent investigation and inquiry into the safety of the building well that's echoed all down the years he constantly asking and is constantly refused
02:22:58 refused now on that page he goes on to other issues and on uh succeeding pages including i'm not going to read at all obviously the lifts come into it maintenance of the lift garden
02:23:09 maintenance of the lift garden maintenance can we please turn to a very important section
02:23:14 section and headed fire alarm health and safety
02:23:22 we are very shocked uh to learn at the bottom of zero zero five if you've got that page yes at the very bottom perhaps it could be enlarged for those who who want to follow it
02:23:36 we are very shocked to learn from you that you consider the defects in the building exposed by the fire as a minor fault
02:23:42 fault when it potentially fatal consequences the minor fault caused so much damage to individuals living in the grenfell that's difficult to imagine how serious an event has to be for you to consider in a major fault
02:23:53 to consider in a major fault if the fire alarm system isn't functioning and the vents are not working i pause we compare that 2017 what's changed
02:24:04 we compare that 2017 what's changed very little should be considered no doubt as a major fall they're used as measures to save life they're not working and obviously you're endangering the lives of residents in the building what's more we're certain
02:24:15 we're certain that out of 120 families living in the block no one is aware of the evacuation procedure
02:24:19 procedure why because of course there isn't one we have never had evacuation procedure booklet sent to us for the past 36 years is it not necessary by law to test fire alarms and
02:24:30 necessary by law to test fire alarms and associated equipment on a regular pay basis to check whether the system is fully functional then there's a paragraph about people not hearing fire alarms that
02:24:41 people not hearing fire alarms that nothing's changed on that front and smoke and suffocation he lights upon in the middle of that next paragraph devastating consequences as you know fire does not kill as much as
02:24:53 fire does not kill as much as the effects of smoke and of course that's this case that is 2017 majority of people were suffocated by the accurate smoke
02:25:04 were suffocated by the accurate smoke that went around and to our knowledge some of the residents in relation to 2010 nearly died due to smoke inhalation and suffocation they many residents found
02:25:15 found the whole experience traumatic and mentally damaging then there comes the paragraph just below the staircases the staircases of the surrounding
02:25:26 the staircases of the surrounding high-rise buildings are exposed to open air and natural light and so in case of fire the smoke can easily escape but grenfell tower with its interior case and malfunctioning ventilation system
02:25:38 and malfunctioning ventilation system there is certainly a high probability that the event of another fire the whole building can become an inferno furthermore should a fire occur in the
02:25:49 furthermore should a fire occur in the staircase
02:25:50 staircase there will be no escape route for the residents and rightly so because of the lift and so on and i end this with the last sentence um right at the bottom here before proposed school
02:26:01 proposed school to scroll down a bit to the heading proposed school just above that the residents of grenfell tower have been treated as sub-human and your handling
02:26:13 sub-human and your handling of the incident has been unacceptable that letter has everything in it that letter is warning seven years before the same chief
02:26:25 seven years before the same chief executive officer the same tmo that there will be an inferno it is exactly what was said in the defaun blog which you heard in phase one
02:26:38 and i appreciate the time and i'm going to
02:26:43 to as it were concertina my final remarks into a few seconds rather than minutes the question is why has this been allowed to happen and i'm going to encapsulate
02:26:57 to happen and i'm going to encapsulate it in very short form it's been allowed to happen because of a climate a political climate the political climate in 2010
02:27:11 the political climate in 2010 and 2013 was one in which we use the analogy with the florentine 15th century burning burning bonfires
02:27:24 burning burning bonfires bonfire of the vanities yes well what david cameron actually said was to get rid of the safety culture
02:27:35 was to get rid of the safety culture why it gets in the way of profit those were those were the words that he was using and one can't balk at this at all because if you're going to change
02:27:47 at all because if you're going to change a culture you've got to look at where the culture's coming from but he wasn't standing alone and i opened phase one with that comment about a meeting on the very day of the fire
02:27:58 a meeting on the very day of the fire about deregulation that's what it was all about
02:28:01 all about then and one has to remember that all these events were happening and of course who was the mayor of london at the time the now pres
02:28:12 london at the time the now pres prime minister what was he doing in 2013 just as all this was taking off austerity cuts to fire brigade
02:28:23 austerity cuts to fire brigade fire engines work and jobs and even the training facilities of which there still isn't in in london a training facility allowing
02:28:34 in london a training facility allowing for high rise and when he was taxed about this by andrew dismore in 2013 again it's all part of an attitude of mind boris johnson's response
02:28:46 mind boris johnson's response get stuffed now we're living we were living and hopefully we might come out of that get stuffed when it comes to safety
02:28:57 get stuffed when it comes to safety and of course you link it to something else that boris has recently said as a motivating force he may regret he said it he may want to retract it
02:29:08 said it he may want to retract it we'll see agree greed has a motivating thought
02:29:13 thought not in relation to this issue another issue altogether so we say until you roll back the avarice until you roll back the culture
02:29:23 culture of neglect the culture of discrimination uh that has gone on here then there will be no
02:29:31 be no uh real change and no real hope for those who've had so much faith this is in this inquiry
02:29:39 inquiry including thank you sorry i think i've run over by a bit well only a fraction if you have at all uh mr mansfield so thank you very much for your opening statement
02:29:51 for your opening statement um well i'm now going to invite mr williams from queen's council to make a supplementary opening statement on behalf of the same core participants so just check that you
02:30:03 core participants so just check that you can see me and hear me mr williamson i can sir good thank you very much now can i just mention this that uh on on the program that i've got you are
02:30:14 are done to have half an hour before lunch at one o'clock and course one hour at two o'clock i don't know quite how your statement is going to work out perhaps you don't either i don't know but if at one o'clock you think that you
02:30:27 but if at one o'clock you think that you could finish within a reasonable time by which i mean let's say 10 minutes and say i think we'd all be perfectly happy to let you do that on the other hand it's not that's not to put pressure on you if you'd rather
02:30:38 you'd rather break at one o'clock or a convenient point around then and come back and finish after lunch that's equally acceptable yes thank you so much
02:30:47 so much yes i i've got i've got a carefully worked out timing and uh i'll i'll take your viewers to where we are when we get to well exactly we'll get to that stage thank you very
02:30:58 we'll get to that stage thank you very much mr chairman mrs esteban mr act for i shall deal first uh with uh topic two and the core issue for this topic is for the inquiry to ask itself
02:31:09 for the inquiry to ask itself how the tower itself home to many vulnerable residents came to be a building that was so defenseless when it came to the risk of fire
02:31:19 fire it was of course unprotected in the face of what we now know was a massive risk namely a situation in which as the phase one report made clear the external walls of the building
02:31:30 the external walls of the building actively promoted the spread of fire standing back from the detail there is a stark and simple question if the tower had been the subject of adequate far risk assessment in the
02:31:42 adequate far risk assessment in the years
02:31:43 years leading up to 2017 how was it that 72 people
02:31:47 people died in a catastrophic fire this was a fire safety failure on a monumental scale
02:31:54 scale at the heart of this failure was the tmo its personnel lacked the relevant skills to provide a safety strategy to protect the tower against fire and they took no adequate steps to
02:32:06 and they took no adequate steps to ensure that other suitably skilled persons were engaged to carry out
02:32:11 carry out fire safety work there was in fact at all relevant times no fire safety strategy in place without such a strategy the basis of an integrated approach could not
02:32:23 integrated approach could not exist x over failed to provide a strategy
02:32:27 strategy a failing which was not recognized by them the tmo rbkc or ryden indeed from at least 2010 onwards grenfell's fire safety was in a perilous state
02:32:40 fire safety was in a perilous state the tma then reached an agreement with the fire brigade that any remedial works identified in fire risk assessments would be made fully compliant within five years
02:32:52 five years this was an extraordinarily lax and leisurely timetable showing how complacent at best the tmo were about fire safety this approach was
02:33:03 were about fire safety this approach was entirely contrary to the interests of the residents and demonstrated also a reluctance on the part of the lfb to utilize their enforcement powers
02:33:14 to utilize their enforcement powers in fact as dr lane states in her report over the next five years the risk level rose from medium to intolerable meaning that the premises should not have been occupied at all
02:33:25 should not have been occupied at all until the risk was reduced over these years the tmo essentially entrusted all fire risk masses to carl stokes as the fire risk assessor he was not a
02:33:37 as the fire risk assessor he was not a chartered car engineer and he lacked the necessary skills to carry out the work as regards his qualifications we emphatically do not agree with the view expressed by mr todd one
02:33:49 with the view expressed by mr todd one of the inquiries experts that quotes little if any special competence is required
02:33:54 required in relation to the principles of fire safety to enable a competent fara risk assessor to carry out a type 1 fra for a high-rise block of flats such
02:34:05 fra for a high-rise block of flats such as grenfell tower indeed i should make it clear at this stage that we do not agree with mr todd's general approach and do not accept that he is an appropriate expert to guide the inquiry
02:34:17 appropriate expert to guide the inquiry we echo the criticisms made in relation to his evidence this morning by ms barwise and mr freedom in relation to all
02:34:25 to all relevant masses the inquiry should therefore take its cue from dr barbara lane in any event the tmo's faith in stokes was not universally held by others
02:34:37 universally held by others in a meeting between the tmo and the lfb in january 2016 rebecca burton of the fire brigade quotes raised her concern that our far-risk assessor sometimes
02:34:48 that our far-risk assessor sometimes makes statements which are not justified or supported and that the fra reports need to include justification for statements made the tma however relied on stokes to give
02:35:01 the tma however relied on stokes to give advice on the refurbishment works that would have been more appropriate if he had been a consulting engineer rather than unregulated fire assessor with no
02:35:11 with no full engineering qualifications as dr lane puts it the tmo appears to have instructed mr stokes quotes to undertake ad hoc inspections
02:35:23 quotes to undertake ad hoc inspections of the works mr stokes recorded these inspections in letters to kctno i've seen no evidence says dr lane as to how
02:35:32 how misery or the tmo addressed issues raised by mr stokes in these letters which do not appear to have been part of any of kctno's formal processes or procedures
02:35:44 formal processes or procedures crucially and compounding this error the tmo
02:35:48 tmo excluded the building's facade from stokes's scope of work he did not take exception to this despite the fact that his brief asked him to consider
02:36:00 him to consider the compartment on complimentation of the building and any possible shortcomings with it simply cannot be considered when a wall is excluded from scope
02:36:12 is excluded from scope on any view the exclusion of the facade from the assessment was an extraordinary omission clearly the facade was of critical importance and urgency
02:36:24 critical importance and urgency in august 2016 a fire had occurred on the 18th floor of shepard's court an 18-storey tower block in shepherds bush clanting on the outside of that building
02:36:35 clanting on the outside of that building comprised polystyrene and plywood insulation panels tess concluded they were the likely cause of the fire spreading up the outside the similarities to greninville was
02:36:47 the similarities to greninville was striking
02:36:48 striking flames began pouring from the open window of the seventh floor kitchen quickly spreading up the side of the building at the time the publication inside housing described
02:36:59 the publication inside housing described the fire as a stark warning for social landlords
02:37:05 landlords eight months later in april 2017 the lfb wrote to laura johnson of rbkc to say that testing showed that the combustibility of the panels at shepherd's court
02:37:16 shepherd's court did not meet the levels expected to comply with building regulations this letter caused ray to ask stokes whether the cladding recently installed at grenfell complied with building
02:37:27 at grenfell complied with building regulation requirements he replied in an email sent from his mobile phone that quotes grenfell was glad but the cladding complied with the requirements of the
02:37:38 complied with the requirements of the building
02:37:38 building regulations lots of questions asked of writings
02:37:42 writings and answers received back from them in an internal email the next day ray reported that she had quotes checked with carl stokes who had investigated the details of the
02:37:54 investigated the details of the installation with ryden when the works were on site and he confirmed that the installation complied with the current requirement of the building regulations in fact ray had misrepresented
02:38:07 in fact ray had misrepresented stakes's two-line email which had not addressed the nature of the cladding at all
02:38:14 all the last fra completed before the fire shortly after the completion of the refurbishment noted that the tower appeared to have appropriate fire separation
02:38:25 appropriate fire separation and compartmentation and from a visual inspection of the structure no areas of rage appeared to raise concerns stokes felt it appropriate to make these
02:38:37 stokes felt it appropriate to make these unqualified comments but he did not firstly assess the materials used in the construction of the cladding secondly complete or recommend any
02:38:48 secondly complete or recommend any invasive
02:38:49 invasive invasive assessment of the materials three thirdly seek the input of a charted fire engineer fourthly consider material classification or materials safety
02:39:01 classification or materials safety data sheets for the cladding or fifthly make any inquiry of the basis upon which building control had passed the glad the cladding
02:39:12 had passed the glad the cladding both williams and ray of the tmo now rely heavily on the words in stokes's
02:39:18 stokes's fra assessment that the building appeared to have far separation separation appropriate fire separation and compartmentation this reliance is
02:39:29 and compartmentation this reliance is clearly misplaced given they were both aware that stokes had not been instructed to consider the external facade of the tower as to all this dr lane concludes not
02:39:41 as to all this dr lane concludes not surprisingly that neither miss stokes mr stokes nor ms ray
02:39:46 ms ray nor her superiors in the tmo dempan's demonstrated competent understanding of the hazards posed by the works at the time and they did not make a suitable and sufficient assessment of the risks
02:39:59 and sufficient assessment of the risks to relevant persons moreover in relation to this building clad as it was in combustible cladding and in respect of which stokes had never been asked to consider the external
02:40:11 been asked to consider the external facade
02:40:12 facade evacuation planning had never been made part
02:40:15 part of the tma's procedures for tower residents indeed in her witness statement
02:40:22 statement ray takes a dismissive view of any requirement for evacuation plans saying quotes it was also not our role to capture where disabled and vulnerable people might be living in
02:40:33 and vulnerable people might be living in the tower
02:40:35 the tower this type of information where available was kept
02:40:38 was kept by the neighborhood management teams which were part of the operations department that approach is clearly contrary to the non-delegal
02:40:51 is clearly contrary to the non-delegal strict duty of the tmo that were under to ensure
02:40:55 to ensure so far as reasonably practical that residents were safe from harm it also ignored the relevant guidance on the topic
02:41:04 the topic as the responsible person safety officer under the
02:41:08 under the 2005 sso at fso ray should have ensured the tmo discharged its evacuation planning safety duties the tmo did not
02:41:19 planning safety duties the tmo did not engage with this at all it did not take resident safety in the event of fire seriously for example councillor blakeman to whom mr mansfield's already referred
02:41:31 mr mansfield's already referred whose area included the tower notes in her witness statement that following the refurbishment quotes residents received no advice about fire safety and only after several
02:41:42 fire safety and only after several representations were instructions as to what to do in the event of a fire installed on the walls of the communal hallways
02:41:51 hallways it was left to the residents themselves to be proactive in order to obtain this advice indeed the statements which have been given across the entire group
02:42:03 given across the entire group of the bereaved survivors and residents suggest that the tma's practice in relation to the provision of fire safety information was grossly deficient many residents
02:42:14 was grossly deficient many residents reported
02:42:15 reported they were not given fire safety advice or information about what to do in the event of fire the fras suggests that stokes
02:42:26 the fras suggests that stokes did in fact understand that evacuation planning was essential in the event of fire however he appears to have thought that evacuation planning could be affected ad hoc
02:42:37 affected ad hoc by either the far service or residents themselves which is contrary to government guidance and represents a flagrant disregard for safe residence safety there is no
02:42:49 for safe residence safety there is no reference in any fra or the documented emergency plan neither did the tno produce any document on the subjects this was a serious breach of their
02:43:00 this was a serious breach of their legal duties to the bsrs furthermore as ms biowize has explained there were no tmo drafted peeps i individual plans for means of escape
02:43:11 individual plans for means of escape from fire
02:43:13 from fire in place in the tower for any of the residents
02:43:16 residents this was despite the existence of well-known and long-established guidance on vulnerability some 20 or so tower residents were vulnerable in one way or another
02:43:28 vulnerable in one way or another stokes did not prepare any peeps at grenfell
02:43:31 grenfell he apparently understood that ray's team were drafting them as with so many of those involved with the tower he relied upon an unjustified consumption assumption
02:43:43 consumption assumption the tiano tmo's non-delegable duty to keep the residents safe was not in any way diluted by any residents
02:43:51 residents mental health issues or physical vulnerability on the contrary it placed a burden on the tmo
02:43:59 the tmo to ensure that any such vulnerabilities were accommodated tmo should therefore have ensured that there were in place adequate peeps for disabled and
02:44:10 adequate peeps for disabled and vulnerable residents it failed to do so furthermore stokes advised the tmo in 2014 that the lifts were far fighter lifts even though this was not the case
02:44:23 even though this was not the case on the night of the fire this caused an avoidable loss of life others would with limited mobility and mental health vulnerabilities may have lost their lives because they
02:44:34 may have lost their lives because they did not feel able to utilize the lifts to evacuate i will return to the issue of the lifts in a moment the evidence on topic two will show
02:44:46 the evidence on topic two will show there for the following things one there was at all relevant times no fire safety strategy i.e no overarching basis of fire safety
02:44:57 overarching basis of fire safety engineering in place two stokes was not qualified academically vocationally or by experience to carry out the complex fras that
02:45:10 to carry out the complex fras that grenfell acquired three the fras were wholly inadequate in particular in that they did not deal with the facade and external envelope of the building
02:45:21 the building four there was no or no adequate evacuation plan and no emergency plan five no proper consideration was given to
02:45:32 no proper consideration was given to vulnerable residents and six no peeps were prepared
02:45:40 i turned now to topic three deals with a diverse range of issues
02:45:50 of issues concerned with the operation and maintenance of the tower although these issues are various they have a unifying theme the failure of the tmo to ensure that
02:46:01 the failure of the tmo to ensure that the tower was properly and safely operated and maintained the tmo then carried out works as we have seen in modules one and two
02:46:12 as we have seen in modules one and two which involved fixing to the tower highly flammable cladding products turning the tower into a death trap the building was in view of the series of failings i am
02:46:24 in view of the series of failings i am about to consider singularly ill-equipped to respond to or withstand a catastrophic fire dealing first with the doors
02:46:36 dealing first with the doors the tmo and a company called mounts entered into contracts for flat entrance door replacements in 2011. this was an ideal opportunity
02:46:47 in 2011. this was an ideal opportunity to ensure that all the doors were fire safe
02:46:50 safe was safe it was not taken indeed instead the contracts failed to specify
02:46:58 specify the doors performance requirements the tma was well aware that it was necessary to ensure that all the doors in their estate were far safe indeed in january 2010
02:47:11 safe indeed in january 2010 ray had informed a meeting of the tmo's health and safety subcommittee that quotes the main issues being raised were in relation to
02:47:22 were in relation to one inspection and if necessary replacement of flat entrance doors in enclosed blocks to ensure they present a sufficient level of fire resistant resistance
02:47:34 resistant resistance are self-closing and fitted with intumescent strips and cold smokes seals and as another point where flat entrance doors are demised
02:47:46 where flat entrance doors are demised to lessees can they be persuaded to replace them with appropriate fire-rated doors can we enforce this in respect of leaseholders if not it is
02:47:57 in respect of leaseholders if not it is the fire assessor's view that we would need to adopt an evacuation strategy within our blocks and not defend in place and this has significant information
02:48:08 significant information implications for the installation of automatic detection etc in the event the leaseholders doors were not subsequently replaced and neither was an evacuation plan put
02:48:20 and neither was an evacuation plan put in place
02:48:21 in place it is likely that many of the leaseholders would not have been able to afford
02:48:25 afford new doors given the relatively low number of leaseholders the tmos should surely have included them in the replacement program no doubt they did not do so because of
02:48:36 no doubt they did not do so because of concerns over costs by february 2013 by which time the door replacement program for the tenants was substantially complete
02:48:47 tenants was substantially complete the tmo reported to the gtla the grenfell tower leaseholders association that quotes we've recently had a far risk assessment for grenfell tower reviewed
02:48:58 for grenfell tower reviewed and the s assessor advises that none of the properties at grenfell tower has are highlighted as having potentially non-compliant entrance doors it seems therefore that
02:49:09 entrance doors it seems therefore that the doors
02:49:10 the doors currently installed provide sufficient fire resistance this was dangerously complacent advice it also ignored or forgot the concerns
02:49:22 it also ignored or forgot the concerns expressed in 2010 furthermore various non-compliances were noted in stokes's
02:49:30 stokes's june 2016 significant findings and action plan including non-compliant entrance doors and newly fitted doors which did not have cold
02:49:40 have cold smoke seals some of the doors had had their intumescent strips painted overs some staircase staircase doors did not fully close and the 16th floor door was damaged
02:49:53 and the 16th floor door was damaged there were therefore multiple examples of fire safety breaches
02:49:58 breaches indeed on 17th november 2016 the london fire and emergency planning authority sent a notification of fire safety deficiencies in respect to
02:50:09 fire safety deficiencies in respect to grenfell tower to ray in her capacity as the health and safety manager of rbkc this set out numerous alleged breaches of the fsa
02:50:22 breaches of the fsa failures highlight a systemic failure on the tma's part to take action indeed this was not just at grenfell but also
02:50:31 also in other blogs in december 2016 a tmo safety board update was issued for is following deficiency noises issued against four tmo properties
02:50:44 issued against four tmo properties including the tower this referred to several notices queried with the lfb and expressed surprise as having received the notices on 16th march 2017
02:50:59 on 16th march 2017 just three months before the fire the tma's
02:51:02 tma's health and safety committee met to uh review the fire strategy and provide an update on self closers the the minutes record and could we have
02:51:14 the the minutes record and could we have a cst
02:51:17 a cst zeros 65 at page five
02:51:42 mr williamson we have it on our screens
02:51:46 that's not the right document if we could get rid of that i'll just move on because
02:51:50 because time is short um the um i was referring to the minutes of mark 2017 uh which which in summary recorded that there had been a discussion with um rbkc in march of 2017 in
02:52:04 with um rbkc in march of 2017 in relation to the issue of self-closing devices and it had been agreed that there was no need to deal with them and if the lfb
02:52:17 to deal with them and if the lfb were to make that a priority then the tmo quotes would take legal advice
02:52:23 advice and make representations the gla in in advance of in instigating any inspection program what is so striking is that the tmo were
02:52:34 what is so striking is that the tmo were determined to do nothing if they could possibly do so and to spend money if they had to on lawyers
02:52:40 lawyers rather than on improving fire safety
02:52:45 lfb's senior fire safety officer mr finn subsequently visited the tower [Music]
02:52:53 [Music] and produced a report this is dated 18th june 2017
02:52:57 june 2017 but was clearly prepared before the fire he noted that a significant number of the self-closing devices on the composite far doors to dwellings above the
02:53:07 above the the third floor had either had the self-closing device removed or this revised device was broken and still in place but ineffective
02:53:18 and still in place but ineffective it is unclear what action was taken by the tfo
02:53:22 the tfo tmo to rectify the many outstanding fired or failures prior to the fire in however in view of the history of non-compliance it is likely that either no action or
02:53:33 it is likely that either no action or insufficient action was taken on a related issue in april 2018 the government legal department on behalf of the mhclg wrote to this inquiry setting out the
02:53:45 wrote to this inquiry setting out the results they had obtained having tested mance doors in various london
02:53:51 london boroughs to ascertain their fire resistance on 14 doors tested only one survived longer than 30 minutes the only compliant door was manufactured in 2009
02:54:04 compliant door was manufactured in 2009 indicating that mantis manufacturing after 2009 had a direct effect on door quality mance's technical manager mr duncan is noted by other witnesses to have
02:54:16 noted by other witnesses to have instructed changes to manufacturing that affected the door's integrity and the cadum companies production team leader mr whitten confirms in his witness statement the
02:54:27 confirms in his witness statement the the impetus behind the drop in manufacturing standards was to save money
02:54:32 money the experience of those we represent underlines all these failures they speak of replacement doors where door closes broke shortly after being installed and were never fixed
02:54:44 being installed and were never fixed fixed and the doors never functioned properly
02:54:47 properly they speak of lobby fire doors that would not close in short there was a long and sorry history of defective and
02:54:58 and sorry history of defective and inadequate fire doors at grenfell tower the tmo never addressed this satisfactorily or at all the lfb attempted to do so but ineffectually
02:55:09 ineffectually the door's poor quality had a significant impact on the spread of smoke and flames throughout the building returning then to the lifts
02:55:22 returning then to the lifts the lifts at grenfell tower should have been farther fighting lifts but they were not in 2004 apex lifts were appointed by buckley
02:55:33 apex lifts were appointed by buckley young lift consultants to refurbish all three tower lifts to the latter's specification however this refurbishment did not specify file fighting lifts even though the concept
02:55:45 fighting lifts even though the concept of the fire fighting lift had been in force for some years prior to this first lift project the tmo butler young and amer apex do not seem to have
02:55:56 and amer apex do not seem to have considered compliance with the objectives of fire fighting lift requirements all of them should have been keenly aware of the requirement for the lifts at grenfell to have such a capability the failure to
02:56:10 to have such a capability the failure to upgrade the lifts in 2004 and the lack of consideration in the intervening years was a grievous safety bridge the ramifications of which had grave consequences in 2017.
02:56:25 had grave consequences in 2017. what is particularly poignant is that this upgrade could have been achieved for a cost of about twenty thousand pounds or three percent of the total contract price
02:56:35 price three percent is a small price to pay particularly given the importance of these
02:56:41 these firefighting lift features the inquiries lift expert mr hawkins has observed that he would have expected a recently competent lift consultant to have considered modernizing the lifts
02:56:54 to have considered modernizing the lifts to the fire fighting standard and we agree it was then a further lift project in 2014 2015 this too did not address the issue of an
02:57:04 of an upgrade to modernize the lifts to the firefighting standard it should have done so
02:57:10 done so in may 2015 the tno produced an internal document called the kctma fire safety policy and strategy section 18 of that document dealt very
02:57:23 section 18 of that document dealt very briefly with fire safety and lifts however it did not reference a single standard
02:57:29 standard having regard to the standards that should have been considered the combined effect which give definition to the concept of a far-fighting lift the tmo document is clearly inadequate
02:57:41 the tmo document is clearly inadequate the tmo undertook no reasonable review when compiling it many essential features were omitted furthermore the lifts were not adequately inspected or maintained
02:57:54 adequately inspected or maintained the report prepared by wsp on the lifts in 2018 after the fire confirmed that the towers lifts were not interfaced with the lobby smoke detection systems
02:58:06 with the lobby smoke detection systems the level 2 farm and switch was disconnected and the ground floor switch inoperable it is clear from the witness evidence that the tmo did not test the fire control switches
02:58:17 control switches weekly as required under the british standard had they been tested the tma would have identified that the switches were inoperative and would have should have fixed or replaced them
02:58:28 them this became an important issue on the night
02:58:31 night of the fire in summary the lifts were at all relevant times not fire fighting or evacuation lifts
02:58:43 fire fighting or evacuation lifts and they were furthermore defective and inadequate those with mobility issues depended on these lifts to self-evacuate the tmo were fully aware of these
02:58:56 the tmo were fully aware of these shortcomings but took no step adequate steps to address
02:59:00 address the same so um i've got about another 10 to 12 minutes so shall i continue would you prefer to do that i'm quite happy that you should if
02:59:11 that i'm quite happy that you should if you
02:59:11 you i think it would be it would be better to do it all in one piece if i may of course yes and i'm not absolutely promising 12 minutes but that's what i'm hoping for thank you you carry on thank you so i turned then to
02:59:22 turned then to uh maintenance uh from 1996 onwards rbkc had teleget delegated to the tmo all the relevant repair responsibilities
02:59:34 all the relevant repair responsibilities through a management agreement contract it is apparent that these responsibilities were not well discharged as long ago as 2009 following a detailed
02:59:45 as 2009 following a detailed investigation mariah marmoli reported that there were a number of tenants leaseholders and freeholders within the borough who felt aggrieved that their
02:59:56 borough who felt aggrieved that their problems had not been resolved by the tmo
02:59:59 tmo by several despite several years of complaining the concerns dealt with included repairs service charges and the like
03:00:10 repairs service charges and the like and the report went on to say that the tmo now needed to tackle not only the governance but the real operational issues around the services it provided to meet the demands
03:00:21 the demands of the residents within the borough and she said this the new board needs to win the hearts and minds of these disgruntled residents who've had grievances going back several
03:00:32 who've had grievances going back several years
03:00:33 years the board must understand its constitutional and legal and take collective responsibility to spearhead the tmo in its improvement plan in december 2009
03:00:45 in its improvement plan in december 2009 mr black
03:00:46 mr black already referred to reported to the tmo board
03:00:49 board that the rbkc adjudication report had now been published and the rbkc and the tmo
03:00:56 the tmo have an agreed strategy to manage it manage any issues which are arising this was a reference to another report by mr butler on long-standing complaints of residents of the tmo
03:01:08 of the tmo despite the so-called agreed strategy matters did not improve over the next few years tenants and leaseholders were in frequent communication with the tme
03:01:19 communication with the tme tmo with a view to persuading them to carry out their obligations in respect of maintenance adequately however the tno often seemed unwilling or unable to do
03:01:31 often seemed unwilling or unable to do so
03:01:32 so this lack of attention to maintenance had disturbing consequences for example in 2014 rge services a specialist company engaged by
03:01:43 services a specialist company engaged by max fordham to report on the vent system told them that they had advised of quotes every service to the tma that in the event of an activation
03:01:54 in the event of an activation we cannot guarantee that the system will work
03:01:57 work in march 2014 the lfb carried out an inspection and noted a number of maintenance failures with worrying effects for example that no suitable system of monitoring was in
03:02:10 no suitable system of monitoring was in evidence
03:02:10 evidence to identify deficiencies with the smoke ventilation system and that about 30 percent of the aov vents were in the open position all this indicating a general failure to
03:02:22 all this indicating a general failure to maintain the system the lfb gave formal notices of these hypnosis of these and other deficiencies regarding grenfell tower to the tmo on
03:02:33 regarding grenfell tower to the tmo on 24th march 2014. moreover as with so many other aspects of the refurbishment there was a striking lack of clarity as to who was supposed to be dealing
03:02:45 as to who was supposed to be dealing with maintenance issues during the currency of the works or thereafter indeed as early as october 2016 issues relating to the maintenance of the completed system
03:02:56 the completed system were apparent an expen an inspection noted
03:03:00 noted the actuators were not working correctly on the aov system there were multiple examples there are multiple examples from our clients
03:03:09 clients of the lifts being commonly out of use and the liftor was not closing over extended periods of time resulting in service outages nonetheless
03:03:20 resulting in service outages nonetheless the tmo seems to have taken the view that it could handle maintenance in issues entirely in-house on a site village
03:03:28 village visit with williams on 24th october 2016 mr white of jsw accompany engaged in this area recalls in his witness statement that he quotes
03:03:39 statement that he quotes mentioned to her that it was important to set up a maintenance log and use people
03:03:44 people who understood the plant and equipment this
03:03:47 this involved regular sometimes daily physical checks of the equipment and the display panels to see if anything was out of the ordinary i formed the impression that the tmo would get these checks done
03:03:59 would get these checks done by their on-site caretaker rather than by their external maintenance contractor this complacency was not justified by events
03:04:09 events moreover there was a lack of clarity as to which company was obliged to carry out regular maintenance this lack of clarity extended to the maintenance of the lifts as well
03:04:20 maintenance of the lifts as well mr wallace of pders the company responsible for lift maintenance who inspected the lifts in april and may 2017
03:04:28 2017 has confirmed in his witness statement that he did not see a copy of any operation and maintenance manual
03:04:35 manual when he began working on the lifts at grandfather tower in conclusion as to maintenance what is noticeable as with so many other aspects of the tma's performance
03:04:46 tma's performance is its inability to get to grips with maintenance problems the tower needed a systematic plan for planned print preventative maintenance and reactive maintenance put in place by the tma
03:04:59 maintenance put in place by the tma the tmo then needed to follow up assiduously to sure ensure that what was planned and agreed was put into practice none of this happened at best various
03:05:10 none of this happened at best various organizations responded ad hoc as problems arose often this response consisted in a little more within the assertion than the assertion
03:05:21 assertion than the assertion that some other body needed to deal with the issue
03:05:24 the issue all of this contributed to the poor state of the building on the night of 14th june 2017. indeed a post-fire audit report
03:05:36 indeed a post-fire audit report on tmo's uh repairs direct organization is an indictment of just how
03:05:43 how poor the tmo's own in-house repairs and maintenance organization was concluding quotes it is a reasonable statement that the service one
03:05:54 statement that the service one isn't good quality two performs poorly three is expensive dealing finally with gas
03:06:02 gas on the night of the fire the time taken to isolate the gas supply was wayfully prolonged as mr manfield mentioned
03:06:11 mentioned as soon as the gas was isolated the fire went out
03:06:15 went out what like a light
03:06:18 the background is that due to a failure in the existing gas supply line a new line had to be installed by trio these works were carried out in a
03:06:29 these works were carried out in a chaotic fashion in the early part of 2017 residents raised concerns about the newly installed
03:06:36 installed exposed gas pipework in communal areas and stairwells it seemed to take emails from the residents
03:06:45 residents for either the tmo or the contractor cadent
03:06:48 cadent to do anything about the gas pipeworks the tma were as ever purely reactive as dr lane observes in her recent report it therefore appears that the resident's
03:07:00 it therefore appears that the resident's complaint
03:07:01 complaint prompted tm the tma's top management into pursuing cadent and trio to expedite
03:07:08 expedite the commencement of the far projection works to the gas replacement riser however kctmo top management failed to seek assurance that the risk to relevant persons
03:07:19 that the risk to relevant persons pending completion of those works was being adequately controlled moreover a riser survey undertaken by cadent
03:07:28 cadent at the end of september 2016 did not locate any isolational service valves on either of the two gas supplies entering the tower a subsequent hazard and operability
03:07:40 a subsequent hazard and operability study
03:07:41 study specified the investigation of the reported absence of those well valves it seems however that nothing was done about it this was a clear breach of regulation 13
03:07:53 this was a clear breach of regulation 13 of the pipeline safety regulations of 1996 i.e a failure to maintain the gas supply in good order the replacement service installed in
03:08:05 the replacement service installed in 2017
03:08:07 2017 suffered a similar fate no trace was found
03:08:10 found of a valve surface box and the expected location of the pressure isolation valve either by mr hancock's the police or corgi technical services this is an
03:08:23 or corgi technical services this is an extremely basic safety provision it is highly unlikely isolation valves were not installed the failure to locate the valves on both
03:08:34 the failure to locate the valves on both occasions
03:08:35 occasions was likely to have been due to contractors building over areas where the valves were
03:08:42 were installed the evidence shows in fact a complete lack of information that would have assisted cadent or the lfb in isolating
03:08:54 assisted cadent or the lfb in isolating the in locating the isolation valves the effect of this litany of failures is that the towers gas supply took much longer to isolate than will
03:09:06 took much longer to isolate than will than should otherwise have been taken our clients consider this a very important point the fact that the supply could not be isolated
03:09:15 isolated for any more many hours was as a direct result
03:09:19 result of incompetent design decisions and inadequate construction management decisions
03:09:24 decisions taken many months before the fire so to conclude on topic three we say that the evidence shows that the tmo
03:09:33 tmo and its advisors never got to grip with a range of key issues in particular one the fire doors were defective
03:09:42 defective and dangerous in numerous suspects and as the
03:09:46 as the the lfb reported at the time of the fire they likely provided no protection two due to a pre-considered decision not to plan escape routes there was no
03:09:58 not to plan escape routes there was no evacuation plan three none of the lifts were fire fighting or evacuation lifts four a litany of failures meant the tower's gas supply took much longer to
03:10:11 tower's gas supply took much longer to isolate
03:10:12 isolate than it should have done and five the tower
03:10:15 tower was not adequately maintained much has gone wrong and this will no doubt be investigated at length in the weeks to come however
03:10:28 in the weeks to come however this inquiry needs to think about the future
03:10:32 future as well as the past to ensure that failings of this kind do not happen in the future its recommendations should we suggest include the following
03:10:43 should we suggest include the following matters
03:10:44 matters first of all the obligations on local authorities and other social landlords to consult and inform residents and residents organization
03:10:55 organization [Music]
03:10:56 [Music] organizations on fire and other safety masses
03:11:00 masses need to be strengthened secondly those who conduct fras should be required to have specified appropriate qualifications and should be
03:11:11 appropriate qualifications and should be subject
03:11:11 subject to a professional code of conduct thirdly in high-rise blocks there should be
03:11:19 be clear requirements for the fire safety of all doors whether those of social tenants leaseholders or in communal areas fourthly
03:11:30 or in communal areas fourthly lifts in such blocks should be firefighting firefighting lifts and uh with those observations that concludes my oral opening submissions thank you
03:11:43 my oral opening submissions thank you very much sir and thank you very much to the panel
03:11:45 the panel for your uh listening to us well thank you very much indeed mr williamson and you've done very well you finished within the time that you suggested you uh were aiming for um well that's a convenient point for us
03:11:58 um well that's a convenient point for us to break
03:11:58 to break uh for some lunch we will uh resume at 115 and the next uh speaker who is going to be mr maxwell
03:12:09 speaker who is going to be mr maxwell scott is
03:12:10 scott is expecting to start at 1 at 2 15 so that will suit everyone very well 2 15 then please thank you very much