Opening statements for Module 3 of the Grenfell Tower Inquiry, covering tenant treatment, fire safety failures, and regulatory compliance. The Mayor of London, Fire Brigades Union, and London Fire Commissioner present their positions on TMO failures, institutional indifference, lift malfunctions, and fire risk assessment inadequacies.
00:00:17 good morning everyone welcome to today's hearing today we're going to hear opening statements from three further core participants beginning with uh miss and stud queen's
00:00:29 beginning with uh miss and stud queen's council on behalf of the mayor of london so my first task is to check whether miss stud is there and can see me and hear me clearly good morning mr anthony and i can hear you mr chairman
00:00:40 anthony and i can hear you mr chairman good thank you very much well you're the first off for uh to make a statement on behalf of your client and i think
00:00:47 think if you're ready we're ready when you are thank you
00:00:51 thank you mr chairman and panel members the mayor of london wants to make clear that he regards the dismissive treatment of the tenants of grenville tower
00:01:01 tower when they were making justifiable and as it turned out prophetic complaints to be a disgrace the kensington and chelsea tenant management organisation
00:01:13 chelsea tenant management organisation was everything a tenant management organization should not be it was not community based it was not cooperatively run it was not representative and it was not
00:01:25 it was not representative and it was not responsive to residents needs or feedback
00:01:30 the royal borough of kensington and chelsea had a responsibility to ensure that the tmo was fit for purpose the evidence
00:01:38 evidence overwhelmingly suggests that rbkc failed in its duties to the people it was supposed to serve the inadequacies and failures of the tmo
00:01:51 the inadequacies and failures of the tmo have been considered by maria memoli in her report dated the 10th of april 2009
00:01:59 2009 and yet in spite of her recommendations the tenants in 2012 to 17 were coming up against the same issues that she had identified as requiring remedy
00:02:11 remedy during the programme of works undertaken at grenville tower years after the publication of that report
00:02:19 report when recommendations concerning the need for a single complaints procedure proper use of progress reports to keep the complainant informed swift remedial action and improved
00:02:31 swift remedial action and improved response times had apparently all been implemented the residents of grenville tower were facing strikingly similar problems within a few days of
00:02:43 similar problems within a few days of the tragedy helen mcnamara then director general for housing and planning in the department for communities and local government emailed jeremy haywood the then cabinet
00:02:56 emailed jeremy haywood the then cabinet secretary
00:02:57 secretary with some initial thoughts on wider questions following the fire she posed the question of whether the fire was a tragic incident or a sign of wider system failure
00:03:11 or a sign of wider system failure she then referred to issues such as catastrophic building failure which you mr chairman confirmed in your phase one report
00:03:22 confirmed in your phase one report tenants complaints being left unanswered and issues with social housing regulation such as whether the regulator knew the tmo was failing and the effectiveness of the housing
00:03:34 and the effectiveness of the housing ombudsman
00:03:37 these were issues so obvious to ms mcnamara
00:03:40 mcnamara in the immediate aftermath of the fire and yet in the months before the fire rbkc had been unable or unwilling to acknowledge that the tmo was failing
00:03:52 to acknowledge that the tmo was failing and unfit for purpose as late as march 2017 our bkc were responding to a complaint saying that the tmo is judged to have a
00:04:05 saying that the tmo is judged to have a robust
00:04:05 robust management complaint system which ultimately ends with the judgment of the ombudsman
00:04:12 ombudsman that assessment could not have been more wrong
00:04:17 wrong that the bereaved survivors and residents were being treated appallingly in multiple different ways does not now seem to be an issue but why and how this was allowed to
00:04:30 but why and how this was allowed to continue
00:04:31 continue by rbkc needs to be fearlessly explored the conduct of the tmo towards the residents of grenville tower
00:04:42 the residents of grenville tower demonstrates a total failure in ensuring that grenville tower was a safe place to live
00:04:49 live in fact to the contrary the tno's seeming inability to consider the welfare of those living in the tower as a priority demonstrates a wholesale failure of any
00:05:01 demonstrates a wholesale failure of any tenant management and left people feeling
00:05:05 feeling that they were looked down upon disrespected and ignored those that persevered with trying to get their complaints recognized resolved or even taken seriously
00:05:18 resolved or even taken seriously were branded as troublemakers where it should have provided a bridge between the tenants and their landlords the tmo's failures to engage with the
00:05:29 the tmo's failures to engage with the tenants in any appropriate and constructive way led to deep distrust the mayor refers to just a few examples
00:05:41 just a few examples the tmo was dismissive in relation to a disabled resident when she raised concerns about her safety
00:05:49 safety in a fire and the lack of adaptation to her flat
00:05:55 her flat they were slow and rude when responding to complaints and yet swift to place a padlock on a garage
00:06:03 garage when her tenant was a few days late paying for the space there is consistent and voluminous evidence
00:06:13 evidence of the tmo's unacceptable attitude towards residents this includes references such as they made us feel a nuisance
00:06:25 they made us feel a nuisance she the complaints officer at the tmo was very abrupt and short with me it was like she was angry with me that i was making a complaint
00:06:36 was making a complaint i felt like they thought i was a troublemaker and my impression of the tmo's attitude towards the tower was that it was social housing and that
00:06:48 was that it was social housing and that we
00:06:49 we its residents would get what we were given
00:06:52 given and be grateful for it another example is i feel that the way these concerns were handled is a good reflection of the culture within the tmo
00:07:03 reflection of the culture within the tmo and the attitude it had towards grenville tower residents at the time ultimately we were people who wanted to feel safe in our homes and this should not have been perceived
00:07:15 and this should not have been perceived by the tmo as something which was annoying or bothersome i also believe that as residents in so-called social housing block we were treated as sub-citizens or
00:07:28 we were treated as sub-citizens or sub-class
00:07:30 sub-class does the treatment of residents of grenville tower demonstrate an institutional indifference based upon a perception that social housing tenants should indeed be grateful for what was being provided for
00:07:42 grateful for what was being provided for them for free certainly there is an evidential basis for reaching that conclusion the inquiry must look closely at issues
00:07:53 the inquiry must look closely at issues related to social housing tenants and their treatment by the authorities including the possibility of institutional discrimination racial or otherwise
00:08:04 or otherwise although many residents spoke english as a second language there is a consistent theme that important information was not made available in languages other than english
00:08:15 english and that residents felt that having english as a second language was a barrier
00:08:19 barrier to them being able to make complaints on their own behalf in addition to the grossly substandard service being provided to the residents the tmo also manipulated the complaint
00:08:31 the tmo also manipulated the complaint system
00:08:33 system residents became aware that contrary to published policy telephone complaints were not recorded and therefore not acted upon as all knowledge of them was denied
00:08:45 denied not only was this contrary to publish policy but it also discriminated against those who are unable confidently to register a written complaint in english
00:08:55 english a second method of manipulation of the complaint system was to ensure that a complaint was downgraded to an inquiry in 2015 ttla complaint
00:09:08 in 2015 ttla complaint about the failure to replace the smoke ventilation and the extraction system was converted to a member's inquiry and not recorded as a complaint this robbed the gtla of the opportunity
00:09:20 this robbed the gtla of the opportunity to use the three-stage procedure for the complaints process and to return refer the matter to the housing ombudsman this highlights ms mcnamara's issue in
00:09:32 this highlights ms mcnamara's issue in her email
00:09:33 her email in relation to the effectiveness of the housing ombudsman clearly in the case of the grenville tower residents the housing ombudsman system was ineffective
00:09:44 ineffective but the lack of effectiveness was contributed to by the lack of a clear unassailable complaint system it appears that some of those that did complain soon found out that the tmo and
00:09:57 complain soon found out that the tmo and rbkc complaint system was not fit for purpose
00:10:00 purpose and so simply decided that complaining was pointless this is a position that confidence in the complaint system is as important as the robustness of the
00:10:13 is as important as the robustness of the system itself
00:10:17 the tragedy at grenville has uncovered institutional indifference towards those living in social housing on an alarming scale and with catastrophic results
00:10:29 catastrophic results resident safety should be and always should have been of the utmost priority residents voices must be at the heart of decision making by councils and housing
00:10:40 decision making by councils and housing associations after all they alone know what it is like to live in the building and they literally have to live with the consequences of others actions or in action
00:10:53 residents must have a stronger voice to challenge their landlords to improve performance and there is an urgent need for better representation of social housing residents at national level
00:11:05 residents at national level social housing must be placed at the heart
00:11:08 heart of government plans to increase housing delivery
00:11:11 delivery it must not be treated as a secondary tenure
00:11:16 tenure as part of the equality and diversity and inclusion funding conditions in the new affordable homes programme for 2021-2026 the mayor will champion a stronger voice
00:11:28 the mayor will champion a stronger voice for londoners especially those who are underrepresented or face significant housing-related inequalities the mayor calls for a commission for
00:11:39 the mayor calls for a commission for social housing residents who would give strength to those underrepresented voices the commissioner should be a person who resides in social housing and their role would be to champion the
00:11:50 and their role would be to champion the views and interests of social housing residents
00:11:53 residents and make recommendations to inform future government policy the role of the housing ombudsman is obviously crucial to be effective the housing ombudsman
00:12:05 to be effective the housing ombudsman has to be widely publicized easily accessible and represent the final arbiter at the end of a streamlined and efficient process the mayor welcomes the government's
00:12:16 the mayor welcomes the government's plans to simplify access to the housing ombudsman as proposed in the building safety bill he regrets the delays to the publication of the government's social housing white paper
00:12:27 paper which was due to be published on the third anniversary of the fire but in fact was not published until november 2020 the mayor considers it is vital that the
00:12:38 the mayor considers it is vital that the housing
00:12:39 housing the social housing regulator adopts the more proactive role proposed in the white paper as soon as possible
00:12:45 possible in order to properly monitor and drive compliance with the enhanced consumer standard and with the additional enforcement powers as set out in the white paper
00:12:56 as set out in the white paper a key concern is the overlapping remits of the housing ombudsman the social housing regulator and the new building safety regulator clarity and collaboration around these
00:13:08 clarity and collaboration around these roles are essential as is proper resourcing to enable them to carry out their roles effectively at the heart of this module are the bereaved survivors and residents
00:13:20 bereaved survivors and residents who tell you that they live with the consequences of the fact that in spite of their best efforts they were unable to prevent this tragedy occurring
00:13:30 occurring it is a terrible indictment of this obviously broken system that they should have to live with a feeling of responsibility having tried so hard to make the
00:13:41 having tried so hard to make the authorities listen
00:13:44 topic two will consider the obligations of the tmo and rbkc under the regulatory reform fire safety order 2005 and their compliance with those obligations
00:13:57 obligations for reasons that are to be established in the course of this module the fire risk assessments were unable to identify
00:14:04 identify the very real risks that were presented by this tower the fire at la canal house and the investigations and recommendations that followed
00:14:13 followed were meant to change the approach of social landlords to fire safety forever the fire at grenfell tower shows this was obviously an unfulfilled objective
00:14:24 was obviously an unfulfilled objective but this is an opportunity to fulfill that remit and ensure a robust system whereby fire risk assessments are made available to residents
00:14:33 residents and most of all they are fit for the purpose for which they were designed
00:14:41 the bereaved survivors in residence evidence to you about their concerns about safety will extend to cover issues in relation to the lifts the self-closing mechanisms on fire doors and the smoke control systems
00:14:55 doors and the smoke control systems you've already heard from them in respect of some of their concerns in earlier modules of this inquiry the la canal fire rule 43 letter dated the 28th of march 2013
00:15:08 dated the 28th of march 2013 from the coroner to eric pickles the then secretary of state of the dclg recommended encouraging providers of housing in high-rise residential buildings contained
00:15:20 residential buildings contained containing multiple domestic premises to consider the retrofitting of sprinkler systems the mayor is clear in his view that automatic fire suppressant systems have
00:15:32 automatic fire suppressant systems have a proven record of saving lives protecting residents and reducing property damage by controlling the spread of fire and allowing firefighters more time
00:15:43 allowing firefighters more time to facilitate evacuation and or rescue residents
00:15:48 residents he invites you sir to consider again whether the retrofitting of sprinklers should be mandated and centrally funded by the government in order to avoid future
00:15:59 in order to avoid future catastrophic loss of life
00:16:02 londoners can be assured that the mayor has ensured that all future buildings or gla commission land commissioned under the london development panel will include sprinklers
00:16:13 sprinklers or other fire suppressant measures in all-purpose-built blocks of flats regardless of height all schools and all housing for vulnerable residents this requirement
00:16:25 this requirement has also been introduced into the mayor's new affordable homes program
00:16:31 this module of the inquiry is directly focused
00:16:35 focused upon what action the authorities could or should have taken to avoid the catastrophic events of the 17th of june 2017. it must provide the answers as to why
00:16:48 it must provide the answers as to why residents complaints inquiries and questions were not appropriately answered or resolved and why no one took responsibility for this building being so dangerous
00:17:01 this building being so dangerous in the event of fire when the residents themselves without any expertise appear to have been able to recognize those risks and it must make recommendations that
00:17:14 and it must make recommendations that ensure this can never happen again thank you very much mr chairman thank you very much for stud
00:17:24 the next statement is going to be made by mr
00:17:27 by mr seaword on behalf of the fire brigades union
00:17:31 union mr c word uh are you there yes indeed i am good morning can you see me and hear me all right since you can yes i can thank you good thank you very much well then
00:17:42 thank you very much well then i'd invite you to make your opening statement on behalf of the fbu thank you just go go back up to the top
00:17:55 good morning sir and your colleagues both on the panel and the assessors submissions of those representing the families contained in their written and oral opening submitted statements are most welcome and the fbu
00:18:08 statements are most welcome and the fbu endorses them the fbu has been fighting the austerity cuts deregulation and privatization agenda of central government over the last 15 to 20 years the fbu contends this agenda has decimated
00:18:20 contends this agenda has decimated public services including building control and fire and rescue services weakened the enforcement regime of fire safety rules allowed ambiguity and confusion to pervade the guidance
00:18:31 pervade the guidance and has led to multiple failures in the application and enforcement of fire safety rules and regulations affecting high-rise
00:18:37 high-rise residential buildings like shaheed ahmed and
00:18:41 and edward daffan to name but two amongst the families named by their council yesterday
00:18:46 yesterday the fbu persists it hasn't given up and won't go away the fbu and the firefighters and control staff we represent
00:18:54 represent remain humbled by the suffering of families and committed to a full and open enquiry unlike so many witnesses we've seen in phase two
00:19:02 phase two so far the firefighters and control staff were willing to go into the witness box in phase one without consulting lawyers reframing their evidence and carefully crafted witness statements or seeking any
00:19:13 witness statements or seeking any undertaking from the attorney general they did so out of a sense of public duty
00:19:18 duty they were casualties too being placed in an impossible position and expected to deal with it without an evacuation plan or any training how to implement one they now put their trust in this inquiry
00:19:29 they now put their trust in this inquiry to unearth the causes of the tragedy in these submissions i will focus on the lifting grenfell tower this is not to detract from the importance of the other matters being investigated in all three topics under
00:19:40 investigated in all three topics under module three to which i hope to return briefly time permitting but to assist the panel to address the question why the lifts didn't work as intended on the night of the fire
00:19:50 the fire this matters to the firefighters both because there may have been fatal consequences and because the expert lift engineer assisting the panel mr halkins relies on the witness evidence of lift engine engineers from peters
00:20:02 engine engineers from peters and bureau veritas to suggest the fire control switch was working shortly before the fire and that the reason it didn't work on the night may have been due to the firefighters using the wrong size of key
00:20:13 using the wrong size of key the fbu asked the panel to reject that suggestion for the reasons which are detailed and fully referenced in our written opening submissions i do not repeat them this morning but summarize the main points
00:20:26 before i start a few preliminary points these were not firefighter lifts in the tower as they should have been and as mr stokes wrongly advised they were
00:20:35 were as a result there was no triangular key which would have lessened the chances of a firefighter having a key with the incorrect dimensions and these these lifts could not be used
00:20:47 and these these lifts could not be used to evacuate residents from the tower it's not known which drop release key was used by firefighters on the night and there is no criticism of firefighters sourcing their own drop
00:20:59 firefighters sourcing their own drop keys
00:21:00 keys by at latest 140 the lifts of most of the lift lobbies had filled with thick black smoke and were unusable it follows that the inoperability of the fire control switch
00:21:12 inoperability of the fire control switch is only relevant in the early stages of the emergency response i refer the panel to the fbu's chronology of lift use
00:21:19 use for the details substantiating the submission
00:21:24 structure i propose to describe the file control switch and to explain why it was so important and then to consider the physical evidence of the switch being blocked with builder's debris and how it became
00:21:35 with builder's debris and how it became so blocked and then to consider the unsatisfactory nature of the witness evidence from bureau
00:21:39 bureau veritas and peters then time permitting i'll say a few words on the on the other important issues raised in module three
00:21:48 the fire control switch was an important firefighting control in the tower it was high up on the wall between the lifts it was designed to be operated by an express drop release key inserted through a round hole
00:21:59 through a round hole and turned to operate the switch when operated the switch was supposed to cause both lifts to descend to the ground floor the lift car doors to open and thereafter remain under the control of the firefighters
00:22:11 under the control of the firefighters and unavailable for anyone else because the call buttons higher up the tower should have been disabled this is to protect residents from the known dangers of becoming trapped in heat and smoke in a lift car or lobby the firefighters
00:22:23 in a lift car or lobby the firefighters tried to operate the fire control switch as soon as they got into the tower and again thereafter crew manager secret tried unsuccessfully to 0101 crew manager gallagher tried the fire
00:22:34 fire control switch again at 1.34 firefighter nuttall later removed the drop release key which had been left stuck in the fire control switch the inoperable fire control switch may have had fatal consequences
00:22:47 had fatal consequences tragically three fatalities were recovered in the lift lobby at floor 10 the chairman has found that these people may have been in the lift when it left floor 11
00:22:55 floor 11 and then exited at floor 10 when the car filled with thick black accurate smoke none of the residents would have been in the lift if the fire control switch had worked
00:23:06 if the fire control switch had worked additionally the firefighters were deprived of a valuable firefighting tool mr mcgurk and dr laner agreed that under the firefighters control these lifts could have been valuable tools for firefighting operations enabling them to get to upper floors
00:23:18 enabling them to get to upper floors quickly via the lift carrying themselves and their equipment to reach higher floors in their standard duration breathing apparatus would otherwise allow facilitating longer wears by sparing them the long and exhausting climb up
00:23:30 them the long and exhausting climb up the stairs um operator please show the photographs in mr hawkins's annex at rho 604
00:23:42 rho 604 underscore 0108 and while that's being obtained and put up on screen i asked the question so so why didn't
00:23:54 i asked the question so so why didn't the fire control switch work the fbu contains this is because it was blocked and jammed with physical debris turn now to the physical evidence you can see on the screen on the left
00:24:05 you can see on the screen on the left hand side the notes uh made by the i call the wasp inspectors for operation northerly on the 18th of april 2018. so
00:24:17 2018. so starting with with the note that says the faceplate was removed to determine the reason for failing to operate the switch
00:24:25 switch so they couldn't operate the switch and the next note we discovered that the mechanism was seized and damaged or deformed
00:24:35 uh looking at the photographs now um you'll see that the the top photograph shows the fire control switch screwed flush to the wall with no parts of its inner
00:24:47 wall with no parts of its inner mechanism exposed that's how dr lane found it when she photographed it in the autumn of 2017. it was just the same then please now notice the lower photograph
00:25:00 please now notice the lower photograph and that shows that that shows the um the switch after the wasp inspectors had failed to operate the switch and then unscrewed the face plate to determine the reason
00:25:12 determine the reason the exposed inner mechanism was caped with builders debris i ask you to remember this image both when you look at the next photograph taken after it had been manipulated by by hand by inspectors at deer park on
00:25:23 by hand by inspectors at deer park on the 15th of february 2019 and when considering whether it should have been reconnected in that state as it must have been in august 2016.
00:25:34 andrew sorry andre horn and others inspected the the switch on the 15th of february 2019 in a workshop at deer park to determine why it wasn't working they reported also the microswitch was
00:25:46 they reported also the microswitch was jammed
00:25:47 jammed appeared to be a wall plaster used during the works and they go on to talk about plaster grains on the workbench and build up a builder's material on the top of the switch was from the original works not caused by the extraction of the switch
00:25:59 caused by the extraction of the switch and they noted that the micro switches operated correctly when the jam was cleared according to andre
00:26:07 andre andre horn's later report on the 15th of february 2019 the switch frame arms of the ground floors which were found to be jammed there was some debris evident on the frame
00:26:18 on the frame it goes on to say after some gentle manipulation by hand it moved freely and then he gave their opinion forceful manipulation of a fitting key would have moved the switch
00:26:30 fitting key would have moved the switch frame armed the bent side wards and the switch frame arm did not cause the jam experienced at the start of the examination so um it was only after
00:26:42 so um it was only after the switch had been cleaned of the debris that the fire control switch worked
00:26:47 worked i was going to ask you all to have a a last look at the caked debris on the fire control switch in the lower photograph i wonder operator if you just put that back
00:26:58 you just put that back uh i don't know if you can enlarge the the lower photograph operation again i'm guessing he can't oh that's very helpful thank you
00:27:10 very helpful thank you you can see there that it is indeed as it comes out of the the wall um on the 18th of april 2018 it is caked with builders dust and
00:27:21 2018 it is caked with builders dust and debris
00:27:24 now um operator please put up the the photographs taken on the 15th of february 2019. that's r h r h uh uh zero ah no rh um naught
00:27:37 uh zero ah no rh um naught no rho and then it's uh six zeros four underscore zero two three four
00:27:47 thank you and you can see there this is the photograph taken after the switch had been manipulated by hand to clear the blockage
00:27:58 blockage and you can see that it's much cleaner after that manipulation by hand than it was when it was found on the 18th of april uh 2018. you can actually see in the
00:28:11 uh 2018. you can actually see in the photograph some shiny bits where before it was completely covered with uh with debris to recap the fire control switch had not worked when firefighters tried to
00:28:23 worked when firefighters tried to operate it on the night when they're likely to have applied reasonable force to turn the key nor when wasp inspectors tried to operate it on the 18th of april 2018 it was then taken to deer park
00:28:34 2018 it was then taken to deer park where it was again found to be jammed and didn't work until after some gentle manipulation by hand
00:28:41 hand it moved freely the photographs could be taken down now thank you
00:28:48 the fbi therefore invites the panel to investigate whether the blockage would have prevented firefighters operating the fire control switch on the night whichever type of drop key was used if so it's irrelevant whether crew manager
00:29:00 so it's irrelevant whether crew manager secret and crew manager gallagher and or firefighter knuckle used a key like the one later provided by firefighter nuttle or a standard express drop release key whichever key they used the fire control switch was blocked with
00:29:12 the fire control switch was blocked with builders debris and could not be turned with the application of reasonable force until the plate was removed and the blockage cleared if this is right the blockage is the principal reason why firefighters were unable to
00:29:23 reason why firefighters were unable to take control of the lifts as they repeatedly tried to do accordingly the fbi invites the inquiry to reject mr hampton's conclusion and his paragraph 597.3 but with
00:29:34 and his paragraph 597.3 but with forceful manipulation with a fitting key the fire control switch would probably have worked how how it got into that state the pedal may also wish to investigate how the fire control switch
00:29:45 control switch came to be caked with builders debris shahid ahmed ahmed complained of misuse and overuse of the lifts during the refurbishment and simon lawrence of ryden admitted using the lifts daily
00:29:57 using the lifts daily to get materials up the building so there was plenty of builders dust and debris generated by the works in the vicinity of the ground floor switch
00:30:06 switch mr hawkins has concluded um that during the main refurbishment works the ground floor switch had been disconnected a temporary uh fire control switch had been installed at walkway level on floor two this
00:30:19 at walkway level on floor two this temporary
00:30:19 temporary floor ii switch have been disconnected by august 16. the ground floor fire controls which have been reconnected from about the same time august 2016 and the disconnected temporary fire control
00:30:31 disconnected temporary fire control switch had been left in place on floor two
00:30:33 two whereas it should have been removed the inquiry may conclude that the ground floor
00:30:38 floor uh far control switch should not have been come contaminated with builders debris
00:30:43 debris if it had been secured or covered during the works and thus infer as the fbu contends
00:30:48 contends that it was probably left vulnerable thereby exposed to contamination by plaster dust and debris after the temporary fire control switch was installed at walkway level on floor 2 how else could it have become contaminated by
00:30:59 could it have become contaminated by builder's debris the inquiry might also conclude that the switch should not have been reconnected in august 16 caped with builders dust and debris whoever reconnected it should have
00:31:10 whoever reconnected it should have ordered a new one or at least cleaned and tested the existing one reconnecting it in this state showed a shocking disregard for an essential firefighting feature of the tower and so also for the safety of residents
00:31:22 and so also for the safety of residents it's no surprise that the person who reconnected the switch has not been identified mr howkins has observed that the witness evidence of engineers from bureau veritas and
00:31:33 veritas and peters they tested the fire control switch before the fire and didn't identify any faults and he's reported
00:31:39 reported that assuming that leaders were checking the operation the fire control switch and associated symptoms systems each month it doesn't appear that any other potential maintenance deficiencies would have affected the
00:31:50 deficiencies would have affected the operability of the fire control switch mr halkins acknowledges it's the function of the panel to make fundings effect and the fbu asks the inquiry to investigate whether his assumption can probably be
00:32:01 whether his assumption can probably be made or whether dr lane's approach is to be preferred this is her module 3 report chapter 8 at paragraph 12.2.41
00:32:12 paragraph 12.2.41 i have post fire information by means of witness statement she says from a small number of lift maintenance contractors that this was done i.e inserting rotating fabricates which but just they never once documented it
00:32:24 but just they never once documented it over a seven year period she goes on after a break as there are years of records demonstrating concern about various lift contractors employed by kc tmo
00:32:35 by kc tmo it is not appropriate for me to rely on such weak evidence so i've taken the decision not to rely on it the fbi urges that is the proper cause to take dr lane
00:32:46 that is the proper cause to take dr lane found
00:32:46 found no written records to demonstrate that the switch was ever manually operated in a routine inspection mr hawkins likewise found no evidence of any regular
00:32:57 regular um or any testing of the fire control switch
00:33:00 switch by other people who were supposed to test you so the tmos lyft engineers the gerald honey partnership apex or kelford sedan even though they were all supposed to do so
00:33:12 all supposed to do so there is that's a track record of lift maintenance contractors and engineers not
00:33:16 not testing the fire control switch yet mr crap
00:33:19 crap mr hawkins credits bureau veritas and peters with having done so so it all comes down to the witness statements filed on behalf of bureau veritas and peters these are all self-serving because both
00:33:31 these are all self-serving because both companies were obliged to inspect the fire control switch under the terms of the 2017 procedure for bureau veritas and under their contract with the tma for peters but for the reasons set out
00:33:44 for peters but for the reasons set out in detail in our written submissions the fba invites the panel to find these statements particularly of mr felice taylor and mr wallace of peters and mr lessici and mr arnold bureau veritas
00:33:54 veritas are unreliable in so far as they allege the fire control split switch was inspected and tested and found to be working normally before the fire after the fire of course everything changed
00:34:05 changed our reasons can be summarized as follows any competent lift engineer who inspected the lifts and tested their firefighting features in the months leading up to the fire could reasonably be expected to have
00:34:17 could reasonably be expected to have observed at least three defects one the fire control switch on the ground floor was stiff and difficult to operate and then upon rudimentary inspection that it was damaged and blocked with
00:34:28 that it was damaged and blocked with with debris and to have reported the need to clean and repair it or replace it two the fire recall function was disconnected and upon rudimentary inspection that the
00:34:41 and upon rudimentary inspection that the wires had been cut with straight ends and to report the need to reconnect it the disconnected fire control switch on floor two
00:34:50 floor two should be removed none of them did the inquiry may conclude that was because they were not asked or encouraged to do so by their supervisors and did not do so until after the fire
00:35:03 and did not do so until after the fire certainly there was no record made of any pre-fire inspection or testing of the fire control switch the um the inquiry has just recently decided to dispense with the oral
00:35:14 decided to dispense with the oral evidence of mr felix taylor and instead to read his statement to the record
00:35:19 record the fbu asked the gti team either to reconsider this decision or at least to attach no weight to mr phallus taylor's statement
00:35:26 statement given the partial and self-serving nature of his contentious assertions all of which are based on hearsay or speculation not on what he saw did or heard
00:35:38 have i timed for a few words on the other issues raised in module three i think i do don't i you have a few minutes but thank you well as to topic one the
00:35:49 thank you well as to topic one the fbi welcomes the opportunity afforded the bsrs to explain some of their fire safety concerns before the fire and how they were dealt with by the tmo s topic two the obligations of the tmo
00:36:00 s topic two the obligations of the tmo and rbkc under the regulatory reform uh fire safety order and their compliance with those regulations the fbu notes the divergent opinions of mr tom and dr lane and where they differ
00:36:11 mr tom and dr lane and where they differ invites the panel to prefer the opinion of dr lane it's a great shame careful analysis of the relevant legislation and guidance given on
00:36:18 given on how to implement it such as dr lane has now provided was not commissioned and provided by the dclg soon after the recommendation of her honor
00:36:26 her honor francis kirkham cbe in 2013. aaron pickles then the right honourable eric pickles mp should explain this to this inquiry his different conclusion in 2013.
00:36:38 in 2013. the fbu agrees dr lane's opinion a that grenfell tower is a complex building with a mixture of domestic and non-domestic accommodation with multiple responsible persons and over 300 residents
00:36:49 residents this is patently preferable to mr todd's country opinion but grenfell agrees that grenfell tower required a comprehensive fire risk assessment process carried out by a
00:37:00 assessment process carried out by a competent fire risk assessor within a framework of documented set of fire safety arrangements including a documented and comprehensive emergency plan agree that mr stokes substantially failed to adequately
00:37:12 substantially failed to adequately consider the arrangements for the safe evacuation of people identified as being especially at risk particularly those with vulnerabilities relevant to a fire event
00:37:20 event agree that there was no documented arrangements made by kctua to confirm their employees would arrange a general evacuation of any high-rise residential building and kc tmo made no such arrangements
00:37:32 tmo made no such arrangements for grenfell tower that their fire risk management system for the huge property portfolio of 9476 properties appears to have been woefully
00:37:43 properties appears to have been woefully underfunded whereas adequate resources were required to fund rbkc's fire risk management system
00:37:50 system fire risk assessment borough wide cost a mere 1
00:37:54 mere 1 226 pounds per month for the period for the year ending july 2014 and fire risk assessment works cost just
00:38:04 just 200 000 pounds in the year 2016 to 17 just before the fire dr lane could not find a comprehensive and clear budgeting process for all aspects of kctmo
00:38:16 aspects of kctmo fire risk management system nor understand how the tmo communicated to the borough the resources that were required each year for the tma to adequately implement
00:38:27 implement their fire risk management system and thereby comply with the order the fbi agrees that the tmos and also rbkc's fire safety management system was woefully under resourced
00:38:38 woefully under resourced the health and safety team comprised top down the chief executive robert black who appointed anthony parks until june 2015 and then barbara matthews thereafter as executive director of financial services and ict
00:38:51 director of financial services and ict state day-to-day responsibility and janice ray is health safety and facility managers
00:38:55 managers dr lane found no evidence of kctmo assigning
00:38:59 assigning any persons as specific fire safety managers of individual buildings or groups of buildings against this background it's no surprise that mr stokes submitted the lowest bid of all five tenders for the role of fire
00:39:10 of all five tenders for the role of fire risk assessor all the tmo failed in their primary duty to monitor and review their fire risk assessment program and assure themselves producing suitable and sufficient risk assessments for their premises there is currently
00:39:23 for their premises there is currently no formal designation equivalent to chartership for fire risk assessors and this is a concern the fbi agrees dr lane was unable to find any guidance
00:39:34 find any guidance like the fire risk assessment company councils choosing a competent virus assessor
00:39:39 assessor that would have been in place in 2010 when kctmo first appointed mr stokes once again the fbi makes the point that industries cannot be trusted to regulate themselves after the lack of house fire
00:39:50 themselves after the lack of house fire recommendations uh fire recommendations were entrusted to the fire sector federation whose efforts failed to solve the problem of ensuring adequate training qualification and competency
00:40:01 qualification and competency for fire risk assessors of complex buildings this was a factor in the oldham street fire also leading to senior coroner meadow is recommending that the secretary of state for the home
00:40:12 that the secretary of state for the home department considers measures to ensure that fire risk assessors are adequately trained and qualified serves to be competent in the role and the responsible person has the means to verify the confidence of any person
00:40:23 to verify the confidence of any person holding themselves out to be a pharaoh's cassette dr lane has identified that a well-structured definition of competence and associated qualifications training and experience as well as professionalising the role of pharah's
00:40:35 professionalising the role of pharah's concession would in her opinion be an appropriate focus for recommendations from phase two of the inquiry
00:40:43 uh the local government association uh guidance dr lane is of the view that it significantly downplays for blocks of flats
00:40:52 flats the importance of the planning and recording of fire safety arrangements as well as the need to clearly communicate organizational requirements as part of the duties the responsible person has under the order if the panel agrees that
00:41:04 under the order if the panel agrees that this is a valid criticism it may assist in deciding whether to prefer dr lane's opinion or mr taunts where they differ in respect of complex buildings such as
00:41:15 in respect of complex buildings such as grenfell tower wars finally moving on to topic three the fbu agrees mr hancock's report of the first of october 19 about the installation of a new gas
00:41:26 about the installation of a new gas riser in the stairwell the fbu hopes the inquiry will investigate how and why the possibility of running the new guest writer in the same
00:41:33 same place as the old writer was discounted in discussions between trio and the tmo that's his paragraph 317 it bears the appearance of a shameful disregard of the safety of residents i should say another
00:41:44 should say another shameful disregard of the safety of residents to take the easy option of running it up the sole means of escape thereby further reducing your ready minimal and confined space and introducing combustible material
00:41:56 and introducing combustible material timber and gas to a protected area mr hancock's conclusion is the cadence should have refused to replace the gas riser
00:42:02 riser and offered compensation to the residents instead the fbu hopes the inquiry will investigate the question of whether the decision to place the gas riser in the single means of escape was justifiable on any ground other
00:42:15 was justifiable on any ground other than keeping down costs thank you sir those are my own submissions well thank you very much mr seaword um now the last opening statement which we are going to hear
00:42:26 hear is to be made by mr walsh queen's council on behalf of the london fire commissioner so mr walsh good morning are you there can you see and hear me well i can see and hear you
00:42:38 and hear me well i can see and hear you very well
00:42:39 very well i hope you could see me yes thank you very much well good morning and um if you're ready to make your statement off you go i'm indeed well good morning sam good morning uh ms estella fun and uh mr agbor
00:42:52 ms estella fun and uh mr agbor so having heard the submissions made this morning um just briefly we uh on behalf of the london fire commissioner we would echo the calls by the mayor of london
00:43:02 london uh through miss stud for the introduction of sprinklers in all high-rise residential buildings that is something which the lfb has promoted for many years and campaigned
00:43:13 promoted for many years and campaigned for
00:43:14 for uh mr c woods submissions on behalf of the fbu
00:43:17 the fbu in respect to the lifts of grenfell tower which you've only just heard are well made and we broadly agree with them
00:43:25 with them i can't strengthen those arguments by repetition so i won't try instead on behalf of the london fire commissioner i would like to begin
00:43:36 commissioner i would like to begin these relatively short submissions by recognizing the exhaustive work which the inquiry has carried out in modules one and two which has exposed the way in which the
00:43:48 which has exposed the way in which the maintenance and refurbishment of grenfell tower were carried out so as not only to render what should have been multiple essential fire safety measures
00:43:56 measures ineffective but also to create a situation which caused and actively contributed to the devastating fire
00:44:03 fire on the 14th of june 2017. the the evidence has exposed a truly shocking picture as so many of the core
00:44:14 shocking picture as so many of the core participants have said over the last day or so and obviously the existence or repetition of such a state of affairs is utterly unacceptable there is
00:44:25 is utterly unacceptable there is an absolute necessity in the public interest
00:44:29 interest to ensure that the construction maintenance and refurbishment of premises
00:44:34 premises by and on behalf of building owners includes and results in necessary lawful and effective passive
00:44:42 passive and active fire safety measures and so as you know those fire safety measures are in turn crucial to fire and rescue services when
00:44:53 crucial to fire and rescue services when carrying out their essential core functions and and the extent to which the lfb or any fire and rescue service can or
00:45:04 or any fire and rescue service can or should be expected to anticipate plan for and resource the possibility of catastrophic failures of fire safety measures in the built environment remains a fund
00:45:16 in the built environment remains a fund of fundamental importance to the sector and we submit to this inquiry the expectations that can be properly placed by fire and rescue
00:45:27 properly placed by fire and rescue services
00:45:28 services on its personnel is a critical aspect of that question the fundamental failure of basic fire safety measures in buildings such as grenfell tower present an obvious serious risk not only to
00:45:40 an obvious serious risk not only to residents
00:45:41 residents who are clearly the primary concern but also to firefighters who depend on the existence of such measures when carrying out their duties at great personal risk
00:45:54 at great personal risk and the importance of protecting the safety of firefighters in the complex process of developing fire and rescue procedures for catastrophically failing buildings is often ignored or at
00:46:07 failing buildings is often ignored or at least given lower priority than it should be by some commentators but to fire and rescue services it is of the highest importance not only because they owe a duty to their employees
00:46:19 duty to their employees but also because the risks to firefighters who are deployed into buildings in the most dangerous of circumstances which may result in significant injury or worse has a direct impact
00:46:32 injury or worse has a direct impact on the safety of the public the people who they are trying to protect or rescue at an incident but now the inquiry's focus turns
00:46:43 but now the inquiry's focus turns through module three to consider how if at all the hazards presented by the tower
00:46:49 the tower has refurbished uh were or should have been identified and once identified how they could or should have been responded to and a key element of that work revolves
00:47:01 and a key element of that work revolves around the adequacy or otherwise of the fire risk assessment carried out buyer on behalf of the responsible person
00:47:07 person under the regulatory reform fire safety of 2005
00:47:11 of 2005 the rro the inquiry has the benefit of a wide range of factual evidence and expertise to absorb and assist in reaching its conclusion including in
00:47:22 in reaching its conclusion including in particular the evidence of colin todd and dr barbara lane who are both eminent experts in their specialist fields
00:47:32 fields in relation to dr lane's analysis one aspect of chapter 10 of her report requires some observation in our opening submissions to you that
00:47:43 in our opening submissions to you that is
00:47:43 is the lfb's position as to whether or not the external envelope of a building was caught by the terms of the rro
00:47:55 what is not in doubt is the desirability of its clue inclusion and by that we mean a clear legislative requirement whether it's found in the rro
00:48:06 it's found in the rro or in some other relevant legislation but the lack of clarity within the rro itself
00:48:13 itself as it was originally and is currently drafted
00:48:16 drafted is commensurately undesirable but whatever the merits of the very different views expressed by dr lane and mr todd in
00:48:28 expressed by dr lane and mr todd in their expert reports which are variously deployed by core participants in their opening statements the inescapable fact is that it has been and is now necessary
00:48:40 is that it has been and is now necessary to change the terms of the legislation to resolve the problem uh it is of note that the current fire safety bill amends the rro
00:48:50 the rro so as to expressly apply it to the building's structure and external walls and common parts including the front doors of residential flats
00:49:01 flats and now whether these amendments can probably be understood as clarification or extension of the scope of the rro they have
00:49:08 they have in reality been received as changes welcomed by the public and industry bodies alike and expected by government to increase the burdens on persons
00:49:19 the burdens on persons responsible for multi-occupancy residential buildings and quote provide for increased enforcement action in these areas particularly where remediation of acm
00:49:31 particularly where remediation of acm cladding
00:49:32 cladding is not taking place in other words the change in the terms of the legislation was is necessary to allow enforcement action
00:49:44 is necessary to allow enforcement action to be taken with certainty as the government anticipates
00:49:50 but so notwithstanding the lack of clarity
00:49:54 clarity in the terms of the rro the benefits of desirability of including the structure and external envelope of buildings within its scope lay behind assistant commissioner steve
00:50:05 lay behind assistant commissioner steve chirrex
00:50:06 chirrex letter to london boroughs and social housing landlords of the 23rd of march 2009 and in our written submissions we provide references to that document
00:50:17 provide references to that document as to where it can be found and indeed to other documents which we will refer to in a moment but those considerations also informed the exerted content in chapter 10 of dr
00:50:30 the exerted content in chapter 10 of dr lane's report of the notice of fire safety deficiencies issued to the tmo in respect of trellic tower
00:50:38 tower on the 19th of september 2012.
00:50:43 however at those times during those times of
00:50:47 times of uh enforcement the lack of clarity in relation to external envelopes of buildings remained a considerable problem
00:50:56 problem for enforcement for enforcement bodies and for a broad range of other stakeholders the lachenal house fire and the investigations that followed underlined the continuing lack of
00:51:09 underlined the continuing lack of clarity
00:51:10 clarity so that clear advice had to be sought and was sought by the lfb from the responsible government department
00:51:19 uh in response in letters to the lfb in february and again in december of 2013 the government response was effectively that the requirements and powers set out
00:51:31 that the requirements and powers set out in the rro were not in its view applicable to the external structures and surfaces of residential buildings the reasoning given in those letters was
00:51:44 the reasoning given in those letters was that the rro does not apply to domestic premises as is unquestionably the case saving in the most limited of circumstances and it would be artificial so goes the
00:51:56 and it would be artificial so goes the reasoning to exclude the exterior walls from the domestic premises which they surround
00:52:02 surround and it was also pointed out in the letters that other legislative legislative mechanisms were available to secure
00:52:09 secure fire safety standards in particular the building regulations 2010 as they then were
00:52:15 were and the housing act 2004 but nonetheless following the receipt of that view from the government department the lfb continued to consider what means
00:52:27 the lfb continued to consider what means were at its disposal to raise awareness with building owners of risks imposed by external envelopes of buildings even if the formal enforcement tools set
00:52:39 even if the formal enforcement tools set out in the rro were not available uh and this the letter of the assistant of assistant commissioner dan daly of the 6th of april 2017 sent to local
00:52:51 of the 6th of april 2017 sent to local authorities including rbkc did not assert expressly that an assessment of the external envelope itself fell within the scope of the rro
00:53:02 the rro but it was carefully and deliberately clout crafted by assistant commissioner daley to set out the strength of the lfb's concerns
00:53:14 out the strength of the lfb's concerns and its expectations in light of the fire at shepherd's court including the provision of quote all relevant information about any replacement window
00:53:25 replacement window and facade schemes to fire risk assessors
00:53:30 assessors so as to ensure that the fire and other safety risk assessments were carried out in full understanding of the relevant built environment and so the lfb remains of the view that
00:53:43 and so the lfb remains of the view that this
00:53:44 this is and was a proper expectation of a building owner and a responsible person
00:53:51 person of course the fire risk assessment process does not and cannot function as an audit
00:53:57 an audit of the built and constructed environment but
00:54:00 but a fire risk assessor instructed by a responsible person is dependent on the adequacy and accuracy
00:54:08 accuracy of the information which is supplied
00:54:13 so assistant commissioner daley's letter to rbkc
00:54:18 to rbkc in april 2017 and to other london bureaus
00:54:23 bureaus the lfb's commitment to building pragmatic
00:54:27 pragmatic partnerships with local authorities by sharing known fire safety risks with building owners and promoting public safety
00:54:38 safety that commitment is also apparent in the lfb's engagement with both the tmo and rbkc which i know will be explored further in module 3.
00:54:52 will be explored further in module 3. but apart from the need for clarity in the terms of the rro there are obviously broader issues which fall to be considered in module three and in later modules high on the list of
00:55:05 and in later modules high on the list of those issues as is made clear in the submissions on behalf of the bereaved survivors and residents
00:55:12 residents is the overriding need to ensure that residents vulnerabilities are accommodated to ensure their safety in case of fire that is particularly so in the
00:55:23 fire that is particularly so in the social housing context and it must we say include the allocation of suitable properties in suitable locations in high-rise
00:55:35 in suitable locations in high-rise premises where the use of stairs may be the primary or only means of escape during a significant fire and just as i decide here we would point out
00:55:46 point out that the presence of a working fire firefighter lift while extremely valuable for a variety of reasons is by no means a complete answer to that
00:55:57 is by no means a complete answer to that question
00:55:59 question now this is one of a number of issues which have national significance for fire and rescue services and building residents alike and the lfc strongly believes that the inquiry would
00:56:11 strongly believes that the inquiry would benefit
00:56:12 benefit from the views of the national fire chiefs council on a range of those issues
00:56:20 but sir the lfb continues to look to the future
00:56:24 future in developing its response strategies to fire
00:56:28 fire risk in high-rise residential premises it has not only conducted an extensive review of policies and procedures for information gathering assessment of risk and operational firefighting
00:56:41 risk and operational firefighting but has also commissioned a significant uh
00:56:45 uh number of research projects to inform ongoing learning among those projects and here we give a couple of small but important
00:56:55 important examples of a much bigger piece in partnership with the university of bath research has been conducted into the physiological effects of firefighters
00:57:06 firefighters who are deployed into high-rise buildings in which active and passive fire measures may have fundamentally failed one of the purposes of that research
00:57:16 research is to determine the extent to which firefighters can be deployed in a way which does not place them as unacceptable risk to their own safety and as a consequence to that of the
00:57:28 and as a consequence to that of the people who are they are required to assist uh it is expected that the results of that research will be of national and international significance because as far as we are aware
00:57:40 as far as we are aware no similar research has been undertaken anywhere
00:57:43 anywhere worldwide uh another research project this time in the field of communications has informed the imminent introduction by the lfb of a system by which
00:57:55 of a system by which fire survival guidance information can be viewed in real time at the same time in the control room and on the far ground using devices
00:58:07 and on the far ground using devices provided to incident commanders and at the bridgehead inside the building it's expected that the introduction of that new system will positively influence the development of operational procedures
00:58:19 development of operational procedures by fire and rescue services nationwide and finally sir the evidence which the inquiry
00:58:27 inquiry has examined in modules one and two has been highly informative to the lfb in its ongoing review and learning process
00:58:38 process module three insofar as it relates to the vital requirement for building owners to conduct suitable and sufficient assessments of fire risks in their premises will provide an opportunity to underline
00:58:51 will provide an opportunity to underline a principle which is of great importance to fire and rescue services the safety of occupants of high-rise residential buildings and the ability of fire and rescue
00:59:03 and the ability of fire and rescue services
00:59:04 services to carry out their work effectively in case of fire is wholly dependent upon a robust system of risk assessment and the rigorous
00:59:15 rigorous amelioration of the identified risks by building owners and other responsible persons
00:59:23 persons well so those are the opening submissions on behalf of the london fire commissioner unless i can help you further
00:59:30 further well mr walsh thank you very much indeed those are very helpful uh remarks thank you um well that brings to an end the oral opening statements there are other written
00:59:41 statements there are other written opening statements which will be available for people to read but that concludes the oral opening statements the next step in the inquiry is to begin taking
00:59:52 taking uh evidence from witnesses we shall do we shall begin to do that on the 19th of april
01:00:00 april and we hope and indeed expect to be able to resume
01:00:04 to resume limited access hearings at the inquiries premises
01:00:08 premises at bishops bridge road
01:00:12 in those circumstances it only remains for me to
01:00:15 for me to close the hearing for the time being and to reiterate that we shall resume at 10 o'clock
01:00:22 o'clock on the 19th of april when we shall begin taking evidence thank you very much