Grenfell Tower Inquiry - Modules 5 & 6 (Firefighting) Closing Statements - Monday 24th January 2022 (1/2)
00:00:28 good morning everyone welcome back and welcome to today's hearing today we're going to hear closing statements from some of the core participants in relation to module 5 and the first
00:00:40 in relation to module 5 and the first part of module 6 which was concerned with firefighting the first we're going to hear from is mr friedman queen's council on behalf of some of the bereaved survivors and residents
00:00:52 residents good morning yes mr freedman the failures of the lfb at grenfell tower were six-fold all foreseeable all preventable
00:01:03 all preventable and all in their own way causative of the extent of loss of life one
00:01:09 one firefighters and managers remained in ignorance of catastrophic construction risks posed by cladding fires even though those risks were known about within the organization and cladding
00:01:21 within the organization and cladding fires were increasing in their frequency in the uk and around the world two premises risk assessments were carried out incompetently and in a fashion that did not meet the requirements of law
00:01:33 did not meet the requirements of law policy or the safety of firefighters or members of the public three
00:01:39 three the incident command system in terms of its training continuing education and preparation was profoundly insecure with anything out of the ordinary liable to overcome it
00:01:50 to overcome it four
00:01:51 four there was no developed thinking at all let alone teaching and guidance about how to support high-rise residential evacuations five
00:02:02 five the lfb tolerated inadequate fire ground radio communications and especially so in relation to the barrie headsets that firefighters wear to communicate with their bridgehead and incident commanders
00:02:14 their bridgehead and incident commanders but which do not work properly in high-rise buildings and finally six the control room was simply unable to cope with a complex incident involving
00:02:25 cope with a complex incident involving multiple cause the fire ground control could not coordinate properly and the result was to make matters worse indeed far worse
00:02:33 far worse each of these six failures was foreshadowed at lachnal house in 2009 that fire involved rapid external spread across cladding panels
00:02:45 across cladding panels the premises was woefully under assessed the incident commanders were overwhelmed residents self-evacuated without stay put advice being revoked radios did not
00:02:56 put advice being revoked radios did not work and the control room provided false reassurance that firefighters were on their way when they were not the repeat of these failures should be deeply unsettling to anyone who has
00:03:08 deeply unsettling to anyone who has studied the evidence they have caused the present commissioner to accept that the organization can no longer expect to be trusted but must prove that it can be it was notable that even when inquiry
00:03:20 was notable that even when inquiry witnesses were able to identify and indeed regret their errors mary many still found it difficult to explain them an organization can no more trust itself
00:03:31 an organization can no more trust itself than be trusted if it cannot recognize why it has failed those explanations are not just about blaming external forces they lie in the deeper roots of
00:03:42 they lie in the deeper roots of governance culture and education and can i ask for the documents manager to therefore bring up bsr five zeros 101
00:03:53 five zeros 101 which is our table on failures and underlying explanations the failures are on the top line i've just set them out but the underlying explanations are in
00:04:05 but the underlying explanations are in the line below governance culture education health and safety compliance and accountability it's that line below that needs to be properly looked at
00:04:17 that needs to be properly looked at because the leadership and the fbu are fearfully defensive about criticizing anything that is perceived to go to their core identity and values panel there are deep rooted problems
00:04:29 panel there are deep rooted problems that need to be addressed as we said in the opening if not now when
00:04:34 when and if you don't deal with underlying causes in your report who will turning then to those failures we start with catastrophic construction risk and we could take the table down please
00:04:46 we could take the table down please the inquiry knows that hazards of cladding systems including their constituent parts were documented in landmark reports and national policies from 1999 through to 2014.
00:05:00 from 1999 through to 2014. this included reporting by parliamentary select committee generic risk assessments and national operational guidance if we stopped just there the lfb would have been negligent not to
00:05:11 the lfb would have been negligent not to prepare
00:05:12 prepare however
00:05:13 however despite denials by some witnesses lachnal house was amongst other things a cladding system fire and significant parts of the lfb knew this
00:05:23 this commissioner dobson wrote to the government in december 2009 to warn them of the causal contribution of external war panels at lachnal house that he feared were more widely used in march
00:05:35 feared were more widely used in march 2010
00:05:36 2010 the lfb submitted a study of two tall buildings the greater london assembly that pointed to polymeric material which it advised was probably now prevalent around the sector and which could spread
00:05:48 around the sector and which could spread fire through innovative construction designs such as cladding systems bypassing cavity barriers or fire stopping measures in a further letter to government in december 2012
00:06:00 december 2012 commissioner dobson asked for better guidance on building regulations quote particularly with regard to the spread of fire over the external envelope of the building and not least because such a fire
00:06:12 and not least because such a fire particularly in tall buildings has the potential to affect multiple stories simultaneously thus making firefighting more difficult the lachnal inquest concluded in march
00:06:23 the lachnal inquest concluded in march 2013
00:06:25 2013 amongst other things the coroner recommended that the government review requirement b4 of approved document b to the building regulations she too asked for quote regard to the
00:06:36 she too asked for quote regard to the spread of fire over the external envelope of the building and the circumstances in which attention should be paid to whether proposed work might reduce existing fire protection in a
00:06:47 reduce existing fire protection in a separate letter to commissioner dobson the coroner recommended that steps be taken to ensure that incident commanders were given enhanced training to anticipate that a fire might behave in a
00:06:58 anticipate that a fire might behave in a manner inconsistent with the compartmentation principle the lfb's down forward grenfell tower was caused by this external recognition
00:07:09 was caused by this external recognition about the risk of cladding fires not translating into sufficient internal action
00:07:15 action to teach the rest of the organization about them
00:07:20 the failure was firstly vertical because there should have been effective transfer of knowledge down to the station based firefighters
00:07:31 station based firefighters national guidance in the gra 3.2 required training and competency to develop
00:07:37 develop knowledge skills and understanding for firefighters on the impact of fire on the building's construction and recognition of the signs and symptoms of risk of rapid and
00:07:48 symptoms of risk of rapid and unpredictable fire spread and the adoption of appropriate tactics to mitigate these however
00:07:56 however none of the training including the specially commissioned lachnal house case studies and incident command exercises ever prepared operational firefighters to know about
00:08:07 operational firefighters to know about let alone effectively respond to a rapid external fire spread or breach of compartmentation on multiple floors the lfb failure to educate its station-based firefighters is all the
00:08:19 station-based firefighters is all the more inexcusable because in the two years before the grenfell tower fire the fire safety department did the following things
00:08:27 things it trained itself about the risk of cladding fires in those various presentations that the inquiry has seen it continued to write to local authorities about the risk of cladding
00:08:39 authorities about the risk of cladding panels as it did in april 2017 with regard to the shepard's court fire it drafted letters to government signed by the newly appointed commissioner cotton continuing to decry the
00:08:51 cotton continuing to decry the weaknesses of the regulatory regime and he even participated through dac hughes in an external conference where it advised others on the dangers of
00:09:02 advised others on the dangers of cladding fires all of that points not only to a vertical failure to transfer knowledge down
00:09:08 down but horizontal failure across the governing structure of the lfb the failure of communication is striking none of the senior figures saw the two buildings facade slides
00:09:20 buildings facade slides many of the leading officers who the inquiry has heard from did not see or know about commissioner dobson's correspondence with government several key figures did not sufficiently appreciate the doubts that had been
00:09:31 appreciate the doubts that had been raised about the stability of the regulatory system neither could they recognise that fires at lachnal house and shepherd courts foreshadowed the risk of whole building cladding fires and therefore a grenfell
00:09:43 cladding fires and therefore a grenfell tower
00:09:45 tower various witnesses told you that the fire safety department remained in a silo and in that silo it made its disastrous error to assume that documented international examples of cladding fire
00:09:57 international examples of cladding fire infernos could not happen in england because of the strength of our regulatory system the assumption was made without systematically studying the evidence of the foreign fires including their
00:10:08 the foreign fires including their regulatory context or seeking national fire service or government intervention to do so
00:10:13 to do so it ignored the commissioner's letters to government calling attention to the weakness of the regulations it lost sight of the various papers produced by dc dexter between 2000 and
00:10:24 produced by dc dexter between 2000 and 2014
00:10:26 2014 which both challenged the preconception that building failure was rare and doubted the competency of external assessors to comply with fire safety laws
00:10:37 laws the fact that the scale of the fire construction catastrophe at grenfell tower was unprecedented in the uk fighting history can be no consolation for the truth that its
00:10:49 consolation for the truth that its dangers were foreseeable to the lfb panel
00:10:54 panel from that failure of foresight all other failures followed from lachnal house to grenfell tower the lfb remained in breach of its premises assessment duties because it neither
00:11:06 assessment duties because it neither taught its employees to identify cladding systems or discharged its duties under statute guidance and policy to make sure that the risk was documented as part of standard planning for high-rise fires
00:11:18 for high-rise fires guidance from the health and safety executive made it clear from 2010 onwards that the collection and accessibility of risk critical information including construction hazards was an essential function of
00:11:30 hazards was an essential function of pre-planning for operational incidents the government's poorest guidance in 2012 provided the information gathering duties under section 72d of the fire and
00:11:42 duties under section 72d of the fire and rescue services act extended to details of construction type of a building including any cladding materials and internal linings as well as
00:11:53 internal linings as well as occupancy risks concerning restricted mobility
00:11:57 mobility limited comprehension arrangements for assistance in evacuation and children age six and below
00:12:06 below from 2011 the lfb high-rise policy pn633
00:12:12 pn633 had already expanded in appendix 1 to 22 matters to be considered during 72d assessments which included construction features that could promote rapid abnormal fire spread
00:12:24 abnormal fire spread the revised gra 3.2 equally placed importance on the discipline of pre-planning both in terms of comprehending construction hazards that could accelerate external fire spread or
00:12:35 could accelerate external fire spread or breach of compartmentation and unlike the local policies expressly cited classic systems as one such hazard the details of the lfb's failure to
00:12:47 the details of the lfb's failure to planner as follows first
00:12:50 first since the enquiry discovered what it called the woefully inadequate entries on operational risk database for grenfell tower the lfb has established that the
00:13:01 the lfb has established that the inadequacy was not an isolated phenomenon commissioner rowe who became ac for fire stations in december 2017 told you that a full audit of the entire
00:13:13 told you that a full audit of the entire lfb database had discovered a range of inconsistencies poor information and a misunderstanding about risk and necessitating a mass education program
00:13:25 education program second
00:13:26 second lachnal house should have been a lesson in the perils of an under-assessed building
00:13:31 building the local authority was in breach of numerous duties under the fire safety order none of the breaches had been established in lfb's section 72d inspections of the building or by other
00:13:42 inspections of the building or by other information gathering requirements third
00:13:46 third in the years after lachnal house the lfb did not comply with its own policy or national guidelines even though ac brown provided repeated assurances that the system was both robust and compliant
00:13:58 system was both robust and compliant the poorest guidelines were never embedded into lfb practice no one at station level talked of them no blunden policies refer to them a planned study to ensure consistency
00:14:11 a planned study to ensure consistency across stations in identifying operational risk or hazard never took place there was no system to require seven 2d assessments to establish whether occupancy profile included residents who would have had difficulty
00:14:23 residents who would have had difficulty evacuating due to vulnerability comprehension and physical or psychological impairment fourth
00:14:31 fourth ac brown and ac george were provided with a paper from gm elwell in december 2013
00:14:39 2013 that told them in terms that there were substandard entries on the database and that the lfb faced a serious issue of non-compliance with its own service standards
00:14:49 standards ac brown blocked the paper's recommendations and settled for a system that focused on the only on the quantity of premises visited despite this red light advice he had
00:15:01 despite this red light advice he had received on the quantum quality of the work being done fifth
00:15:07 fifth training insofar as it was delivered was not good enough the various witnesses responsible for the training had to accept that amongst other emissions it made no reference to various matters
00:15:18 made no reference to various matters features in appendix 1 of pn 633 or to the modern methods of construction cited in pn 800 it also did not teach crews how to actually do a premises risk
00:15:30 crews how to actually do a premises risk assessment the gist of ac brown's evidence was that people could learn on the job
00:15:37 the job the extraordinary worst of all world situation that prevailed before the grenfell tower was therefore won law and policy over several years required stations to consider
00:15:48 required stations to consider construction features of buildings as part of their 72d duties two senior officers repeatedly told you that they did not believe average station
00:15:59 they did not believe average station firefighters had the technical aptitude to carry out the task and three
00:16:05 and three nothing was done to either enhance station crew competency through training or to delegate the task to competent others
00:16:13 others professor torreira argues that crews absolutely should and could have been trained to follow simple instructions to identify cladding steve mcgurk agrees as dc dexter once suggested in relation
00:16:26 as dc dexter once suggested in relation to insulation materials these kind of things are not rocket science and yet the root of this failure lies in management's belief that firefighters are either incapable or unwilling to
00:16:38 are either incapable or unwilling to learn such a fundamental skill regardless of what was required by policy or the law as well as their safety and the safety of others we say the failure of premises risk
00:16:50 we say the failure of premises risk assessment sent the incident commanders up to fail which leads to the third core failure before the inquiry that the lfb's incident command management system was insecure anyway
00:17:01 insecure anyway in march 2010 the hse issued guidance entitled striking the balance between operational and health and safety duties in the fire and rescue services
00:17:13 in the fire and rescue services it focused on sudden unexpected or unexperienced dangers at incident grounds that required development in the psychology knowledge and preparation of commanders
00:17:25 knowledge and preparation of commanders through training and the provision of information to them on hazards risks and control measures additional government guidance issued in 2013 endorsed the striking the balance analysis adding that command training
00:17:37 analysis adding that command training and management needed to learn human factor aspects of decision making the national operational guidance program then issued new policy which
00:17:48 program then issued new policy which recognized that psychological as well as technical training was necessary to produce constant competent incident command
00:17:56 command the evidence of dr cohn hatton suggested the reform program did not find a comprehending or progressive learning environment in the lfb
00:18:06 lfb commissioner rowe who comes from a military background was also struck by the lack of non-technical training for making decisions under emergency conditions when compared either to combat compared either to
00:18:18 either to combat compared either to combat engagement or policing the failure to adopt the national decision control policy or dcp in place of the long-standing
00:18:29 dcp in place of the long-standing decision-making model or dmm is particularly indicative of the barriers that the lfb faces in change-making the two models are strikingly different
00:18:42 the two models are strikingly different the dmm incorrectly assumes a rational and reflective decision-making process whereas the dcp regards that assumption as part of the problem
00:18:53 as part of the problem and guides the decision maker to review reflex assumptions before acting dr cohen hatton's combined understanding of academia national policy and lfb operational
00:19:06 national policy and lfb operational training confirmed to her that the dmm does not describe the way that people actually think in real world emergency environments and research shows that it is not used even when users claim to be
00:19:20 is not used even when users claim to be relying on it the formal reasons given by operational assurance not to adopt the national guidance do not stand up to scrutiny dcp had been verified by research and
00:19:31 dcp had been verified by research and had been adopted nationally of equal importance long-term research had undermined the dmm as a decision-making tool because of its lack of controls to prevent the mental traps
00:19:42 of controls to prevent the mental traps of cognitive bias and primed recognition it was said that the dcp did not have an equality impact assessment but the lfb never sought one
00:19:53 but the lfb never sought one it also uh but it also ignored the rebuttal opinion from cardiff university that the dcp provided for greater scaffolding for decision making for those with dyslexia
00:20:04 those with dyslexia however
00:20:05 however the dmm has also never been the subject of an equality impact assessment nor has it otherwise ever been established as a safe decision-making tool beyond its broader management consultancy origins
00:20:17 broader management consultancy origins in the 1950s the dominant motive for pushback on the reform was its perception that it was too much too soon for a brigade that was struggling to train incident commanders on the basics let alone matters that
00:20:30 on the basics let alone matters that were new to operational thinking the inquiry now knows that the training of incident commanders was truly poor in terms of technical learning on construction risks and
00:20:41 learning on construction risks and non-technical learning on the psychology of human error with no detailed advice on how to exercise operational discretion even if lives depended on it revalidation training was also
00:20:53 revalidation training was also repeatedly delayed due to lack of command subject matter experts both within babcock and the lfb striking the balance foreshadowed these problems some seven years before
00:21:04 problems some seven years before grenfell tower tellingly commissioner cotton worked in operational assurances from 2012 onwards and led it at director level from 2015
00:21:17 and led it at director level from 2015 but was not aware of the detail of striking the balance and confirmed that no internal auditing was ever conducted to consider whether the lfb was compliant with the guidance it plainly
00:21:28 compliant with the guidance it plainly was not
00:21:31 was not the fourth failure of the lfb at grenfell tower was the absence of any policy or taught method on how to carry out emergency residential evacuation from high-rise
00:21:42 residential evacuation from high-rise buildings
00:21:43 buildings the long
00:21:44 the long and convoluted consultation that led to the revised gra 3.2 formulated a requirement for incident commanders to to consider the need to reverse state pert and importantly to develop training
00:21:57 pert and importantly to develop training and competency on the issue however these key changes on stay put came from civil servants intervening to enforce their secretary of state's undertaking to the latino coroner that
00:22:09 undertaking to the latino coroner that policy change would come very little prior input on these issues came from the lfb or the national fire services or the fbu who clearly all shared in what peter
00:22:21 who clearly all shared in what peter cowep has described as a blind spot on the issue
00:22:26 the issue those in the lfb's operational policy department who drafted the national and local documents did not consult upon or even think through the practical implications of the policy change
00:22:37 implications of the policy change lachnal house training packages did not teach incident commanders about residential evacuation there was also no station training on the revised pn633 to explain what had changed or developed
00:22:49 to explain what had changed or developed in relation to reversing stapler and why the ingrained tendency in lfb residential high-rise firefighting was to assume compartmentation rather than
00:23:00 to assume compartmentation rather than scrutinize its viability and to focus on interview individual crew rescues rather than to theorize about evacuation it was in that mindset that commissioner
00:23:11 it was in that mindset that commissioner dobson told the latino house inquest that he could not even imagine an alternative more dynamic response to building failure he emphasized that senior management saw departure from
00:23:22 senior management saw departure from stay put as operationally problematic but there was never a coordinated consultation with stations and other sources including other services to develop a formal evacuation doctrine
00:23:35 develop a formal evacuation doctrine evacuations nonetheless remain part of the natural behavior of people in fire and events like latino house only encouraged high-rise residents to
00:23:46 encouraged high-rise residents to evacuate regardless of instructions the reactions to these developments within the lfb was primarily to emphasize their management their risk management quality
00:23:57 management their risk management quality rather than developing the strategic responses to facilitate their inevitable occurrence and yet significant evacuation did occur including with the revocation of stay put that was ordered by lfb incident
00:24:09 put that was ordered by lfb incident commanders both at shepherd's court fire in august 2016 and the aid air tower fire in november 2015.
00:24:19 2015. kent
00:24:20 kent fire and rescue services developed a method of high-rise firefighting by 2010
00:24:27 by 2010 which had its roots in the previous decade
00:24:30 decade in contrast to the admitted gaps in lfb operational policy and training this is a system
00:24:36 a system informed by fire engineering skeptical about regulatory compliance and which assumes building failure and evacuation until compartmentation is
00:24:47 evacuation until compartmentation is shown to hold it uses rapid reconnaissance teams to check for evidence of smoke spread above the fire floor on the practical basis
00:24:58 the fire floor on the practical basis that it cannot be justifiable to advise residents to stay put in places in the building that the firefighters have not yet checked kent training uses the rice
00:25:09 kent training uses the rice decision-making tool that helps incident commanders to evaluate under the stress of emergency whether it is safer to prioritize rescue evacuation and containment of a high-rise fire as
00:25:20 containment of a high-rise fire as opposed to automatic intervention to try to fight the fire trainees are taught to identify triggers that would prompt decision making on the reversal of stay put being fire
00:25:31 reversal of stay put being fire development smoke travel self-evacuation and compromised staircases they are features of the first they are these are features of the fire
00:25:42 these are features of the fire that we would emphasize were apparent to early crews that arrived at grenfell tower and those in control especially taking those calls up to 130
00:25:53 especially taking those calls up to 130 and
00:25:54 and 131 but they had no training or policy to act upon them similar reassessment prompts of this nature are now written into all relevant lfb policies and as ac cow up accepted
00:26:07 lfb policies and as ac cow up accepted this should have been done before grenfell if there was a proper inter-service dialogue in the uk then kent memphis should have encouraged a national debate
00:26:19 a national debate instead the lfb have claimed that they knew nothing about them although recollections differ either way the fact remains that the lfb paid little attention to a paradigm shifting policy and training method
00:26:30 shifting policy and training method adopted amongst its neighboring southeast services in circumstances where they had no doctrine of their own the oversight was indicative of a london-centric attitude which commissioner dobson accepted in evidence
00:26:42 commissioner dobson accepted in evidence and was trying to address in his period in office
00:26:45 in office it speaks to a national disconnect which cannot be allowed to continue to exist when it comes to generic risks applicable to all urban fire and rescue services
00:26:55 services as the inquiry has studied the night of the fire like no other previous investigation of its kind
00:27:03 kind it is well to remember what firefighters instinctively feared about triggering an evacuation in the building watch manager dowden thought distressed people confused in that
00:27:15 distressed people confused in that environment made it very very difficult watch manager o'keefe believed it would be impossible and would cause a huge catastrophe d.a.c fenton wanted to prevent a mass
00:27:27 d.a.c fenton wanted to prevent a mass exodus and panic commissioner cotton declared that it would have ended with a significant number of cross injuries with a number of people panicking and trying to get out via a single staircase
00:27:40 out via a single staircase as ac cow up agreed this was an overstated review and referred to his own experience of the 7-7 bombings which indicated the extent to which people were able to behave calmly especially
00:27:52 were able to behave calmly especially when not directly in the vicinity of explosions the future development of evacuation strategy will have to counter the panic myth and to harness the resilience of
00:28:04 myth and to harness the resilience of the crowd rather than to fear it that requires better understanding that residents can support themselves and others from evacuating evacuating from their homes
00:28:15 their homes as has long been the case for commercial buildings
00:28:18 buildings and which is detailed in a generation of research on actual disasters what we want is for this inquiry to contribute to that body of learning
00:28:29 contribute to that body of learning the fifth failure is that the radio equipment worn by the firefighters at grenfell tower didn't work properly inside high-rise buildings its intrinsically safe status compromised
00:28:41 intrinsically safe status compromised its transmission capacity even though nothing else that firefighters take into buildings on fire include the including the equipment designed to mitigate the transmission of these radio to mitigate the problems of the
00:28:53 to mitigate the problems of the transmissions of these radios is itself so-called intrinsically safe professor johnson and professor torreira agree that the equipment was therefore disproportionately sensitive for use in
00:29:04 disproportionately sensitive for use in environments that it was not made for and unjustifiably dangerous given how badly it works when used in those environments from that the key points can be taken quickly first
00:29:15 first almost every firefighter asked about this during phase one told you that the problems with the barrie radios were well known second that is correct institutional knowledge dates back several decades
00:29:27 knowledge dates back several decades from fires arising from high-rise incidents and other disasters both nationally for instance the king's crossfire and internationally the world trade center government risk assessment drew
00:29:38 government risk assessment drew attention to the need for contingency planning in the event of communication failures from 2006 onwards third lachnal house could have been a moment for change the lfb's
00:29:49 moment for change the lfb's communication department internally proposed a wholesale review as the problem would inevitably occur in our inevitably reoccur in other high-rise structures but this was not actioned partly because commissioner dobson saw
00:30:01 partly because commissioner dobson saw the the issue as primarily one of ill-disciplined use of radio channels fourth while other services in the uk and around the world world replaced their low wattage intrinsically safe
00:30:13 their low wattage intrinsically safe sets the lfb did not neither did it ever conduct a formal risk assessments to balance out the dangers of losing communication in high rise towers potentially all the time as
00:30:24 rise towers potentially all the time as against the fanciful safety derived from the equipment that was never designed to support high-rise deployments fifth
00:30:32 fifth gra 3.2 required radio transmission to be considered on section 72d visits and then revised policy number 633 endorsed the need for contingency planning and
00:30:44 the need for contingency planning and expressly expressly required potential communication problems to be given consideration on such visits at grenfell tower however barry sets were not tested only the
00:30:56 barry sets were not tested only the handheld radios and then only to communicate during the visit rather than carry out systemic tests six
00:31:05 six despite the lfb knowing of both the inadequate inadequacies of the equipment and the need to test effectiveness their training did nothing to prepare station crews on either matter
00:31:17 crews on either matter and in fact this training package like other trading packages
00:31:21 packages are one of the uh victims that got lost in the it system and then were never delivered all this fatally damaged situational awareness at
00:31:32 damaged situational awareness at grenfell tower especially in the first hour of the response when crews inside the building knew that smoke had spread to multiple higher floors although countless problems would arise
00:31:44 although countless problems would arise with communication during the night the lost opportunity to appreciate outright building failure in that first hour would have compelled an earlier reassessment of stay put and that must
00:31:55 reassessment of stay put and that must undoubtedly be a significant factor the final
00:32:00 the final and the sixth key failure lies with the control room it can be of no surprise that if the lfb as a whole failed to prepare for catastrophic construction risk and a
00:32:11 catastrophic construction risk and a consequential need to revoke stay put that the control room also remained in a state of incompetency to meet those challenges be that as it may the events during the
00:32:23 be that as it may the events during the latino house fire are crucial to recall control had one assumed compartmentation two offered false reassurance three not coped with the volume of calls
00:32:36 three not coped with the volume of calls four treated all fire survival guidance callers as requiring rescue without exploring their capacity for escape five had no notion of if when or how to
00:32:47 five had no notion of if when or how to revise they put advice and six did not have effective two-way communication with the incident ground we want to address you on four fundamental problems
00:32:58 fundamental problems first
00:32:59 first despite a lacknow house action plan to ensure that control was compliant with national guidance it either failed to comply or simply overlook key parts of the national requirements contrary to
00:33:10 the national requirements contrary to fire service circular 10 of 1993 the fsg refresher training courses were reduced to only half days the numbers who were trained drastically
00:33:21 the numbers who were trained drastically decreased after 2013 because of the competing needs to train on the use of vision the new call handling system active role play was not developed after 2010 at least in part because staff were
00:33:35 2010 at least in part because staff were embarrassed to participate in it and after 2010 fire safety experts only sporadically delivered any training because of other competing needs record keeping was appalling and there
00:33:47 record keeping was appalling and there was never a structured training plan there was an additional fire service circular 54 of 2004 it contained a requirement to assess not
00:33:58 it contained a requirement to assess not only the situation but the vulnerability of the caller by asking about age gender
00:34:04 gender ethnicity and mental or physical ability the lfb
00:34:11 the lfb reached an erroneous view that the circular did not add anything to pre-existing circular 10 1993 and therefore ignored it in fact 10 1993 was silent on the issue
00:34:22 in fact 10 1993 was silent on the issue the lfb therefore failed to deal with vulnerable callers in either its policy its reference information sheets known as rifts or its training there was then gra 3.2 2014
00:34:36 there was then gra 3.2 2014 that added new requirements relating to control room call handling in the context of high-rise firefighting those included the requirement to be ready to re-evaluate stapa advice in communication with incident command and
00:34:48 communication with incident command and to have effective arrangements in place to manage calls from those unable to leave the building due to disability poor mobility illness or the effects of fire
00:34:59 fire this was a major new policy that control room managers told you that they did not know about and there therefore did nothing to comply with
00:35:11 nothing to comply with the second shortcoming of control was key gaps in the local policies policy
00:35:16 policy 539 on emergency call handling contained no warning of the dangers of providing false reassurance to callers and was therefore in breach of circular 1093
00:35:27 therefore in breach of circular 1093 which advised that this may not be appropriate and may even be dangerous in some circumstances appendix 3 of policy number 539 also suffered from potential confusion as to
00:35:40 suffered from potential confusion as to what it meant by affected by fire heat or smoke such as to require evacuation and if so affected how to
00:35:51 evacuation and if so affected how to assess fire behavior to determine whether the caller was actually unable to leave
00:35:56 to leave policy 790 on fire survival guidance accepted in terms that in exceptional circumstances incident command may inform control that
00:36:07 incident command may inform control that their stay put advice should change but the policy provided no explanation as to when or how this would be done and there was no consequence of training or amendment to the rif prompt sheets by
00:36:19 or amendment to the rif prompt sheets by control to enable the change of advice to be made p.o.m hayward's explanation was that control did not ever expect revoking stay put advice to happen
00:36:30 revoking stay put advice to happen som smith agreed and therefore no more was done to prepare for the possibility that it might
00:36:37 the matter was also not revisited as it absolutely should have been when the new gra 3.2 was finalized and expressly contemplated the incident commanders and control rooms should be ready to liaise
00:36:49 control rooms should be ready to liaise on the revocation of stay put the third problem with control service is that there was never a system to register how multiple fsg calls could function as an early warning basis to
00:37:01 function as an early warning basis to consider revoking statefoot pom hayward did not know why the findings and indeed experience from lachnal house where control buckled under five calls did not prompt a change
00:37:13 under five calls did not prompt a change of policy or training he accepted that it should have done however during his time none of the various joint training exercises match the level of multiple fsg calls in latino house or anything more exacting
00:37:26 latino house or anything more exacting it was wrong to assume as ac brown did that the buddy system of overflow calls going to other fire service operators could ever mitigate the problem indeed
00:37:37 could ever mitigate the problem indeed she's with knowledge that the local lfb control room could struggle with situational awareness of what was occurring at a fire ground it was patently a folly to think that the midlands or strathclyde would do better
00:37:51 midlands or strathclyde would do better the final problem with control is that it failed to train or develop policy to deal with the assessment of vulnerable callers and those who were with them this was contrary to national policy
00:38:03 this was contrary to national policy it also constituted a failure to study the profile and characteristics of the deceased at lachnal house this is a point that does not get mentioned but should have been a core concern
00:38:14 concern of the six who died five were from black or other migrant backgrounds and three were children two of the adults to see two of the adult deceased were in contact with
00:38:25 adult deceased were in contact with control as were the relatives and intermediaries of all three adults trying to seek information on their behalf
00:38:31 behalf there was never any instruction on how to speak to a person whose first language was not english or otherwise to be culturally sensitive to people from different backgrounds neither policy 539 nor 790 were the
00:38:45 neither policy 539 nor 790 were the subject of equality impact assessments in their evidence haywood and smith both committed the classic equality impact assessment error to assume that these matters could be dealt with by the intrinsic skills of the call handlers
00:38:57 intrinsic skills of the call handlers without ever any evidence to support that assumption and without developing a dedicated system to guard against discriminatory outcomes that these main problems were allowed to
00:39:10 that these main problems were allowed to languish in control for so long was foremost down to the basic managerial standards being fundamentally absent a key criticism must be made of ac brown
00:39:21 a key criticism must be made of ac brown who line managed a system that was repeatedly the subject of internal reports querying whether the service was working or whether agreed actions were completed
00:39:30 completed dave brown is the key figure in the years before grenfell tower who let these matters lie but the organization also left in place for over a decade an incompetent
00:39:41 for over a decade an incompetent principal operations manager in scott hayward who was simply not good enough to do the job the single key performance indicator that he was required to meet was the speed in staff answering the phones
00:39:54 speed in staff answering the phones no other goals were written down and neither he nor wider control management were held to account the deeper problem was that control remained an insecure and depressed part
00:40:06 remained an insecure and depressed part of lfb service it was always disconnected from operational firefighting but it also treaded water for five years while it waited for the outcome of the regional fire control project that would have
00:40:18 fire control project that would have made london control redundant after 2012 it waited to see if the service would be privatized it then struggled with the introduction of vision software that consumed management
00:40:29 vision software that consumed management focus and available training time as its fate was unknown control training was never outsourced to babcock anyone sentimental or predisposed against
00:40:41 sentimental or predisposed against privatization of training should consider the serious policy in control room trading as a solitary piece of evidence of what happens when the lfb was left to train itself control therefore remained in
00:40:53 itself control therefore remained in another of the lfb silos it lacked the voice management and drive to transform the result was a service that answered phones deployed resources and might reassure callers
00:41:05 reassure callers but it did not have the competency to become an intelligent first and foremost line of response to people in danger neither could it be an information resource and partner to assist in incident ground decision making
00:41:17 incident ground decision making the adverse consequences for grenfell tower were enormous panel
00:41:23 panel if
00:41:25 if those are the failures then what are the underlying causes starting with governance almost every modern study of uk fire
00:41:37 almost every modern study of uk fire service has questioned the capacity of operational firefighters to competently rise from station to senior management without discrete education and the
00:41:48 without discrete education and the support of lateral hire from other industries what you have seen in modules five and six in many ways is the comeuppance for failing to deal with that
00:42:01 failing to deal with that on very basic levels these managers did not understand fundamental features of their role in which we include key performance indicators record keeping information exchange
00:42:13 record keeping information exchange handover and quality assurance their vertical governance structure also encouraged directors and heads of service to become only focused on their
00:42:24 service to become only focused on their own departments and tasks rather than being integrated into a single service which goes some way to explain why there were barriers to change and so many
00:42:35 were barriers to change and so many silos
00:42:36 silos the lack of management skills did real damage
00:42:40 damage commissioner dobson began his post knowing that fire safety was disconnected from the rest of the lfb and that the lfb was disconnected from the rest of the country he retired almost a decade later having solved
00:42:53 almost a decade later having solved neither problem ac brown the third officer presided over a flawed system of high-rise premises risk assessment and chronic mismanagement of the control room
00:43:06 mismanagement of the control room ac cowop spent nearly four years working on a high-rise firefighting policy but left the lfb without guiding local policy and training into being ready to
00:43:17 policy and training into being ready to plan and evacuate in the event of whole building failure ac
00:43:23 ac and then commissioner cotton spent all of her senior leadership years in operational assurance including applicable health and safety but she did not assure service incident command
00:43:34 not assure service incident command readiness for catastrophic high-rise fire risks she was then overwhelmed by the responsibility of the commissioner role and but for the grenfell tower fire she might have led
00:43:46 grenfell tower fire she might have led the organization in siloed incompetence for years to come these people had no doubt excelled as operational firefighters and acted as good faith public servants
00:43:58 good faith public servants but they managed by metaphorically putting out fires rather than strategic insight and vision they were as ill-prepared for their management roles in the lfb
00:44:10 management roles in the lfb as watch manager dowden was ill-prepared for his incident command at grenfell tower
00:44:19 the governance of the organization was very much a product of its culture it is a culture that runs deep and across leaders union and rank and file
00:44:30 across leaders union and rank and file with some of its more problematic attributes being as follows first
00:44:37 first disproportionate virtue and status is afforded to traditional operational firefighting commissioner dobson accepted the accuracy of the characterization of
00:44:49 accuracy of the characterization of operations as the big beast those who rose in the organization held that big b status they excelled in engaging with fire muscle memorizing the
00:45:00 engaging with fire muscle memorizing the standard techniques fitting into watch culture and functioning as hands-on charismatic leaders they were rarely women higher education qualified or inclined to intellectual
00:45:11 qualified or inclined to intellectual horizon scanning they represent an ideal of courage and community a service associated with the 19th century origins of firefighting dr badgett's study refers to the
00:45:23 dr badgett's study refers to the impression of the heroic rescuer contained in the art of the foundation period to make the suggestion that at some deep level firefighters only like to deal with the public if they can save
00:45:34 to deal with the public if they can save them
00:45:35 them can i ask then for a picture cited by a doctor badget to be brought up it's bs five zeroes one
00:45:46 five zeroes one hundred
00:45:55 and that is one of the paintings he looks at
00:45:59 looks at it's charles vigors saved of 1892
00:46:04 of 1892 and it hangs in the fire service college
00:46:09 college it's an iconic image and we say it forms part of the psyche of those that do this job even if they find it difficult to be told that especially by outsiders
00:46:22 told that especially by outsiders and for those who think well this is a 19th century painting and it's part of the past
00:46:27 the past can i ask the document manager to compare it to the fsg's training slide of january 2017
00:46:35 2017 which is
00:46:39 lfb3060350 page seven and have them side by side
00:46:46 a 39 blue watch standard night shift
00:46:51 i don't know whether they saw the painting in the fire service college or it's just so deep that it's a iconic image but they are similar
00:47:02 but they are similar same arm hanging down same message
00:47:09 we say it's no good talking about blind spots without examining their reasons for becoming and staying blind spots there is a group psychological cause to
00:47:20 there is a group psychological cause to why operational responses disproportionately focused on rescue at the expense of any consideration of facilitated escape on some very deep level
00:47:31 on some very deep level it just doesn't fit with the firefighter being the hero in the
00:47:37 you story take the pictures down please
00:47:41 second the flip side of operations being dominant was ambivalence towards less heroic tasks of fire protection and prevention that is why fire safety struggled for
00:47:52 that is why fire safety struggled for recognition both because its subject matter was non-operational but also because all ranks going right to the top struggle with confidence and clarity over the subject we have a service that dumbed down on
00:48:05 we have a service that dumbed down on the science of fire you will recall the flippant exchange of emails between danny cotton and her team in operational assurance on the article about the dubai torch tower fire and its
00:48:18 about the dubai torch tower fire and its flammable acm cladding panels which made reference to paragraph 12 of approved document b cotton explained the emails as a private joke and being flippant
00:48:31 joke and being flippant essentially mocking those who made granular citations to sub-paragraphs on building regulations if cotton is telling the truth she is saying that no one knew what they were talking about and they were tragically
00:48:43 talking about and they were tragically taking the mickey out of the core regulatory issue that went on to cause the grenfell tower disaster and in some ways the truth is worse than them just having
00:48:54 the truth is worse than them just having being negligent about picking it up the third problem with culture was hierarchy
00:49:02 hierarchy and all the mistrust that goes with that from the top to the bottom there wasn't is an unnecessary fear of criticism which is why intelligence reporting and performance review are perceived as
00:49:13 performance review are perceived as punitive rather than educational and why there was reluctance to embrace operational discretion for fear of being ill-judged managers subordinates stations and unions all seem to forever be looking
00:49:26 unions all seem to forever be looking over their back trying steadfastly not to be criticized and consequently failing to develop and changed symptomatic of the point is that we are four years into this inquiry but still
00:49:39 four years into this inquiry but still yet to hear the fbu regret anything about what it did or did not do [Applause] the last issue on culture is that all parts of the organization
00:49:51 is that all parts of the organization have been too ready to assume that discrimination on grounds of race sex or disability has no impact on service outcomes
00:50:00 outcomes the focus has stuck on the willingness to save people from fires but ignored everything else on planning and control we say discrimination undoubtedly damaged
00:50:12 discrimination undoubtedly damaged service outcomes core policies that affected gender race and nationality and disability of residents were never equality impact assessed
00:50:22 assessed national policy that in terms required consideration to be given to those matters as part of premises risk assessment and call handling were overlooked it is an elementary feature of discrimination that no one within the
00:50:35 discrimination that no one within the lfb even noticed that these matters were not in focus until the evidence of this inquiry brought it to the fore disability needs were extraordinarily unconsidered across planning control and
00:50:47 unconsidered across planning control and evacuation the lack of due regard has to be understood against a context in which people with disability are hugely underrepresented in fire services similar points can be made about ethnic
00:50:58 similar points can be made about ethnic minority and women members the lack of diversity in representation inevitably impacts on diversity of thought leading to gaps in service
00:51:09 thought leading to gaps in service defensiveness and lack of curiosity on the subject is unnecessary and in fact an indication of the problem if we turn them to education
00:51:21 if we turn them to education the best way to understand why firefighters were not taught what they should have been taught is to recognize that most of the failures uncovered by this inquiry were of limited consequences to the normal course of
00:51:32 consequences to the normal course of fire ground operations the problems did not arise and therefore the weaknesses did not show the neglect for a mission to train for outright building failure might
00:51:43 outright building failure might therefore be understood as the failure to have due regard to the risk of normalcy
00:51:49 normalcy in other words the potential for the statistical and experienced norm to overly condition both expectation and aspiration for what the organization should be preparing for
00:52:01 should be preparing for that is the normalcy that impaired on the impacted on the education of the lfb and it provides the essential backdrop for the critique of competency provided by professor terrero an organization
00:52:12 an organization especially an emergency service in a major capital city will be fragile if it evolves too heavily by reference to past statistical likelihoods without also
00:52:23 statistical likelihoods without also considering less common but foreseeably severe impact future events high-rise residential firefighting was particularly exposed on this front
00:52:35 particularly exposed on this front past statistics for us for instance those claimed in the lga guy that refer to 22 evacuations of more than five persons during 8 000 fires in flats in
00:52:46 persons during 8 000 fires in flats in 2009 to 10 tell you something about frequency but as torreira emphasized they tell you nothing about severity they also do not reflect that risk
00:52:57 they also do not reflect that risk associated with the built environment is not static such that modern construction methods can quickly transform the probability states for those reasons torreira emphasizes
00:53:08 for those reasons torreira emphasizes that foreseeable risk must always be multiplied by consequences and particularly so when the rarity of an event happening was listening as it was with cladding fires and the adverse
00:53:19 with cladding fires and the adverse consequences if it happened were potentially catastrophic that panel is the fundamental flaw in the lfb's education system there may have been problems with the
00:53:30 there may have been problems with the content and delivery of babcock training but an emergency service that educates itself only in the bounds of normalcy will be profoundly fragile in the face of the exceptional
00:53:43 of the exceptional our further underlying cause is that the lfb fell chronically into breach of health and safety of health and safety obligations the 1999 management of the health and safety at work regulations require
00:53:55 safety at work regulations require systems to be in place to risk assess plan inform and train the fire service related guidance issued by the hsc and dclg from 2010 focused on
00:54:08 by the hsc and dclg from 2010 focused on addressing weakness in incident command and developing information exchange both of which were to be properly supplemented by adequate training policy and monitoring
00:54:20 and monitoring it is manifestly the case that the lfb breached its duties under the regulations and discrete guidance in it unreasonably failed to sufficiently plan inform and train in relation to one
00:54:32 inform and train in relation to one cladding system fires and other material sources of rapid and unusual fire spread two the potential for multiple breaches of compartmentation three revocation of stave put and four
00:54:45 three revocation of stave put and four methodology of emergency evacuation it otherwise failed to comply with the poorest and gra 3.2 documents both regard with regards to preparing fire ground response to identify a cladding
00:54:57 ground response to identify a cladding system fire and with regard to establishing occupancy profile of vulnerable residents who are not able to self-evacuate or seek rescue it equally failed to prepare control to play its
00:55:09 failed to prepare control to play its integral part in the regulification of state booked and provided its own protection of and to provide its own protection of vulnerable and disabled resident callers the bsr
00:55:20 the bsr seek findings on the substance of those matters
00:55:24 matters but the inquiry should also report on how the health and safety standards that you have been referred to were not properly reflected upon in the decision-making of senior leadership and compliance breaches were apparently
00:55:35 compliance breaches were apparently unrevealed to them by internal assurance processes
00:55:39 processes cumulatively and without prejudice to the other wrongdoing discovered by this inquiry this amounts to a serious violation of the state's duty to protect the right to life
00:55:50 the right to life our last
00:55:52 our last underlying cause is lack of accountability the lfb and all other services in england and wales operated for more than a decade without external inspection from her majesty's inspectorate or any
00:56:04 from her majesty's inspectorate or any other independent rigorous auditing as a direct consequence of government policy the result was to leave the lfb without constructive expert criticism
00:56:16 constructive expert criticism commissioner rose singles out this lack of scrutiny as a discreet explanation for the lfb's own failures at self-correction at least by 2016 the danger of this lack of
00:56:28 2016 the danger of this lack of accountability was known to government not least because upon return of the responsibility for fire service to the home office theresa may as secretary of state took immediate steps to
00:56:39 state took immediate steps to reintroduce the inspectorate function what was not recognized then but must be recognized now is that the failures of the lfb did not take place in a vacuum
00:56:51 take place in a vacuum they were forged in the crucible of government policy and practice the inquiry is about to hear that fire service covering government after 2006
00:57:02 service covering government after 2006 was limited to a small department which was cut considerably after 2010 and as a matter of political philosophy was increasingly encouraged to oppose state involvement in the direction of
00:57:13 state involvement in the direction of local brigades the dangers of excessive localism and the cost of running down the centre can be dramatically seen in the erosion of the lfb
00:57:22 the lfb added to this successive governments had presided over the degradation of the building regulatory system such that residents and attending crews in high-rise urban environments were exposed to a risk of disaster that the
00:57:35 exposed to a risk of disaster that the state foresaw and contributed to but did not take steps to prevent in conclusion the
00:57:45 the depth of the failures of the lfb that contributed to this disaster is shocking the brigade was incompetent and incapable at every level to respond to a fire that was extreme but foreseeable
00:57:57 fire that was extreme but foreseeable and it actually in breach of its duties under statute and policy those failings and their underlying causes ought to be recorded by this inquiry in a fashion that ensures that no fire service could ever forget them
00:58:10 no fire service could ever forget them and society from here on can steer its path by them also the sooner the lfb publicly declares and acknowledges its own responsibility
00:58:21 responsibility and acceptance of all the legal and reputational consequences this entails the sooner it will be able to reclaim the trust that its present commissioner accepts that it must earn back
00:58:32 accepts that it must earn back the bereaved and survivors will forever be connected with the lfb even though some were saved many more deaths were avoidable
00:58:43 many more deaths were avoidable and those who were rescued were fortunate to survive in their critical study of the evidence the bsr have therefore done all they can to help the lfb improve immemorial to
00:58:54 to help the lfb improve immemorial to those whose deaths were contributed to by its failures and in support of the recovery of those who survived notwithstanding them the fact that previous inquiries inquests and reforms have been
00:59:06 inquests and reforms have been frustrated makes it all the more essential to achieve the deepest possible understanding of why these things went wrong at grenfell tower in order for that understanding to act
00:59:18 in order for that understanding to act as the guide for what must now be put right
00:59:23 right thank you
00:59:25 thank you well thank you very much mr friedman well the next statement is going to be made by mr thomas queen's council but uh although it's a little earlier than usual we'll take our morning break now
00:59:37 usual we'll take our morning break now to avoid interrupting what he's going to say to us so we'll rise at that point we'll resume pleased at 11 15. thank you very much
01:16:11 the next statement is going to be made by mr thomas queen's council on behalf of the
01:16:16 of the reeves advisors and residents whom he represents so good morning mr thomas good morning when you're ready
01:16:25 a wise person once said mistakes are okay they are our stepping stones of progress if we are not failing from time to time
01:16:38 if we are not failing from time to time then we're not trying hard enough we have to take risks stumble fall and then
01:16:46 and then get up and try again appreciate that we are pushing ourselves learning growing and improving one of the mistakes we fear
01:16:57 one of the mistakes we fear might just be the link to our greatest achievement yet however
01:17:04 however these words of wisdom for them to have power in our lives there needs to be acknowledgement and ownership
01:17:12 ownership of what we have done wrong so that we may improve and grow
01:17:19 it saddens me to say that at least one of the representatives for the interests of the lfb have made it clear that despite the mistakes we've heard
01:17:30 that despite the mistakes we've heard about
01:17:31 about they are not listening they are not learning they are not reflecting reading some of the f o a's closing submissions you would be
01:17:44 f o a's closing submissions you would be forgiven
01:17:46 forgiven for thinking that we are living in some kind of parallel universe
01:17:52 i thought that they were doing some kind of lachenal on you the inquiry they don't like your findings in phase one
01:18:03 one they've already given a clear indication that
01:18:06 that they're not going to follow them indeed they have
01:18:09 they have indicated
01:18:11 indicated in their written submissions to you that they want you to revisit your phase one findings this is arrogance of the highest level
01:18:24 this is arrogance of the highest level the lfb
01:18:25 the lfb need to be told and told in no uncertain terms that this is unacceptable this is an affront to our clients and the memories of those
01:18:36 to our clients and the memories of those who lost their lives modules five and six have shown in depressing detail the systemic failings of the lfb as an organization
01:18:49 of the lfb as an organization an organization with complacent self-satisfied management structure and leadership who are
01:18:56 who are seemingly unwilling or unable or a combination of both to undergo the difficult but necessary task of self-reflection and evaluation
01:19:07 self-reflection and evaluation an organization that would rather than face head-on the very justified criticisms of its structure culture and training provisions would rather block its ears to the clamour for
01:19:20 its ears to the clamour for change in the course of my submissions we
01:19:26 we will be making certain criticisms of the lfb concerning failings and emissions these will be fulsome and forceful and i don't apologize for that
01:19:37 and i don't apologize for that and we submit they are both important and valid
01:19:40 and valid but let's not lose sight of the fact that the lfb did not cause the fire they did not manufacture the materials used to refurbish grenfell tower
01:19:53 used to refurbish grenfell tower they did not make decisions based on maximization of profit margins they are not the ones who are undermining the building regulations and compliance
01:20:04 compliance we have said this in previous openings and closing submissions but it's worth repeating
01:20:10 repeating our clients do not criticize for the sake of it and make a clear and unequivocal demarcation between the brave men and women
01:20:21 women on the front line of the lfb who carry out an incredibly dangerous and brave job while others run from a fire it's their task to run into infernos
01:20:33 task to run into infernos we submit however that the witnesses and the evidence heard in modules five and six have laid bare a number of serious systemic failings
01:20:45 a number of serious systemic failings and inept leadership and management in the lfb
01:20:48 the lfb as an institution these witnesses were at times defensive and unforthcoming with a marked reluctance to provide
01:20:59 with a marked reluctance to provide this inquiry with the open and frank answers that our clients were hoping for the culture and structure of the lfb has undergone some scrutiny in these modules
01:21:11 undergone some scrutiny in these modules and has been found wanting the hierarchy is rigid and inflexible and fosters an insular and over-prescriptive working environment
01:21:23 over-prescriptive working environment there was a clear lack of oversight and leadership and management levels of proaction and of evaluation this all bred a culture of institutional
01:21:35 this all bred a culture of institutional inertia
01:21:38 at the conclusion of phase one so you
01:21:43 so you as chair noted those matters of particular concern which would be further investigated in phase two
01:21:51 phase two matters of particular concern included quote the organization and management of the lfb and in particular in relation to the formulation of policy in the light
01:22:02 the formulation of policy in the light of experience the arrangement of training for firefighters and the control room staff and the arrangement for sharing information about the particular problems associated with fighting fires
01:22:14 problems associated with fighting fires in high-rise buildings we contend that the lfb is an organization that has woefully failed its employees
01:22:26 failed its employees those on the front line who literally put their lives at risk answering any call out the leadership and management of the lfb do these brave men and women a total
01:22:38 do these brave men and women a total disservice they've failed londoners who look to the lfb for insurance maintaining fire safety in the capital moreover
01:22:48 moreover the organization has failed the brief survivors and relatives and their loved ones who died in the grenfell tower fire we respectfully invite the inquiry to
01:23:00 we respectfully invite the inquiry to find that there was a series of systemic failings of the organization some long standing
01:23:06 standing which coalesced with the catastrophic results on the night of the fire we respectfully invite the inquiry to find that they were likely to have contributed to the loss
01:23:17 likely to have contributed to the loss of life
01:23:19 of life on the evidence there have been systemic failings in five areas firstly the section 72d visits
01:23:30 secondly the instant command training thirdly the control room training
01:23:40 fourthly the fsg
01:23:42 the fsg management and fifthly the outsourcing of training for frontline firefighters
01:23:53 for frontline firefighters you see these failings were against the backdrop of the organization's quite frankly appalling response to the la canal house fire recommendations on various points it was either a
01:24:04 on various points it was either a failure to follow a recommendation through
01:24:08 through at others the coroner was misled as to what the lfb were doing to the extent and to the extent that the recommendations were being implemented
01:24:19 being implemented at other points the recommendations were simply ignored
01:24:24 in andy rowe they have a new commissioner determined to ring in the changes commissioner rowe is undoubtedly a
01:24:35 commissioner rowe is undoubtedly a talented and motivated individual he by the standards of the other lfb witnesses in these modules was more candid
01:24:45 candid open and prepared to take ownership of the lfb's failings he spoke very eloquently of the shortcomings and the hopes and his aspirations for the future of the
01:24:57 his aspirations for the future of the service
01:24:59 service that is all to be welcomed and is heartening to hear however
01:25:05 however one man alone cannot change the culture and practices of an entire organization mr o
01:25:14 mr o cannot change the political climate to one in which the public sector generally and our public emergency services in particular are afforded the
01:25:27 services in particular are afforded the the status and commensurate funding that they deserve mr rowe alone cannot change local government for let us not pretend that
01:25:39 for let us not pretend that rbkc
01:25:40 rbkc and the tmo are isolated examples of appalling practice and behaviour in local government in this country
01:25:51 the closing submissions from the cfo and the foa
01:25:56 the foa show the divide and the chasm in opinion within the organization added to that is the voice of the union
01:26:07 added to that is the voice of the union the fbu
01:26:08 the fbu who rightly point out that they had warned of cladding fires and their consequences for several years and sadly
01:26:17 and sadly those warnings went unheeded they also make it clear that the political and economic realities cannot be ignored
01:26:28 cannot be ignored the scale of the task for the lfb is enormous
01:26:31 enormous and the collective lfb evidence in modules five and six give our clients scanned confidence that even with mr rowe at the helm the lfb has the will
01:26:42 rowe at the helm the lfb has the will or the inclination to meet the challenges that it faces in terms of the way in which it is managed its culture and structure and its ability to learn
01:26:53 and structure and its ability to learn and implement change let me turn to lacanol the abject failure to properly and systemically implement the lack of
01:27:05 systemically implement the lack of recommendations is nothing short of disgraceful this is an organization that is unable to reflect unable to listen unable to learn
01:27:16 learn the whole point of learning from previous disasters is to try to put in place
01:27:24 in place measures and changes which mitigate against or prevent a repetition of a disaster history is sadly littered with
01:27:35 disaster history is sadly littered with examples of organizations institutions and individuals being unable or unwilling to learn from lessons of the past
01:27:44 past it takes a non-historian albeit an intellectual titan like stephen hawkins to make the simple point we spend a great deal of time studying
01:27:55 we spend a great deal of time studying history which let's face it is mostly about the history of stupidity history will judge the failures of the lfb along with those of rbc and the tmo
01:28:10 lfb along with those of rbc and the tmo and the corporate core participants and the fact that they did not learn from lachnal
01:28:17 lachnal it is indeed partly the history of stupidity however wedded to that in the case of the lfb was the severely inept and poor leadership a culture that
01:28:29 and poor leadership a culture that fostered institutional inertia a lack of adequate training little or no oversight from management and the political climate of austerity and cuts we make the point in our written
01:28:40 we make the point in our written submissions that the parade of lfb witnesses in module spider and six was a sorry dour sight lacking in motivation dynamism and ideas
01:28:52 lacking in motivation dynamism and ideas there was an all-pervading lack of accountability no one seemed to care enough about the recommendations from lachnal to ensure that they were properly implemented to
01:29:03 that they were properly implemented to ensure that words were translated into action to ensure that the lfb were not simply undertaking a very expensive time-consuming paper exercise to assuage
01:29:15 time-consuming paper exercise to assuage the coroner's fears some in the lfb if the recommendations were too difficult too challenging or contrary to the prevailing lfb beliefs
01:29:26 the prevailing lfb beliefs they were simply ignored such arrogance is inexcusable let me now turn to section 72d
01:29:36 72d section 72d is the foundation of knowledge and the information gathering process upon which ultimately fire fighting strategy is made its importance cannot be underestimated
01:29:50 its importance cannot be underestimated yet the lfb's whole section 72d process had been allowed to fail and fall into an appalling state the fact that it was allowed to
01:30:01 the fact that it was allowed to deteriorate to such an extent is a damn indictment on the lfb and its leadership which they must own acknowledge and rectify
01:30:11 rectify there was a dereliction of duty on the part of the lfb that allowed the section 72d visits to fall into decline in disrepute
01:30:20 disrepute as ever with the lfb there are no shortage of policies there were no less than four policies relevant to section 72d
01:30:31 relevant to section 72d and familiarization visits there was the grah 3.2
01:30:36 grah 3.2 fire fightings and high-rise buildings there was pn 800 management of operational risk information there was the pn
01:30:45 the pn 633 policy note on high-rise firefighting and there was the provision of operational risk information systems which provide guidance for risk and operational
01:30:57 operational management not operational risk
01:31:00 in order to carry out an effective 72d visit there will need to be pre-planning which should have included the identification of the responsible
01:31:11 identification of the responsible persons building owners who should be present at the time of the visit to have an understanding of the state of the building its age any refurbishments etc
01:31:20 etc there needed to be detailed and sometimes lengthy or multiple visits and discussions with the responsible persons re any building regulation issues building materials and the like
01:31:32 building materials and the like and
01:31:33 and there needed to be the necessary follow-up and write-up after the visit the lfb
01:31:40 the lfb has been subjected to the full brunt of austerity and cuts both in terms of funding and numbers this places even more pressures on the remaining crews the lfb is not a
01:31:52 remaining crews the lfb is not a business it is a crucial emergency service serving the public it must be properly resourced in order that it can fully discharge its responsibility and
01:32:03 fully discharge its responsibility and carry out its duties to their fullest most importantly for effective 72d visits proper oversight is needed in the form
01:32:15 proper oversight is needed in the form of an oversight body that can enforce and monitor the proper execution of the act
01:32:23 act and since the fire sorry forgive me since the fire the lfb has been undertaking their own internal review of the governance of the organization but we say that is not enough
01:32:35 enough what is required is an effective body without any vested interest in the organization which can act without fear or favor
01:32:47 or favor let me now turn to training the knowledge
01:32:51 knowledge the training of the lfb personnel across the organization underpins everything the failure to train those employed in the lfb especially at an
01:33:02 employed in the lfb especially at an operational level about cladding fires about compartmentation breaches was catastrophic
01:33:13 there was practically no high-rise firefighting training there was a lack of suitable high-rise training tower facilities
01:33:24 training tower facilities the plain fact is there were and still are in inadequately prepared for the complex combined effect of such a fire
01:33:35 combined effect of such a fire and entirely lacking in practical and realistic training there was no proper incident command training
01:33:45 training there was a failure of babcock to meet training targets in particular in relation to incident commands
01:33:55 commands and there was a lack of adequate training in the control room including fsg management and in terms of knowledge
01:34:06 and in terms of knowledge a misguided and misconceived adherence to stay put as an article of faith the corollary to this being a failure to understand the value and the need for
01:34:19 understand the value and the need for proper evacuation planning for high-rise residential buildings you see
01:34:26 you see public authorities have a duty of accountability the london fire brigade as a public body funded by taxpayers is no different as londoners we expect the lfb to
01:34:38 as londoners we expect the lfb to effectively carry out its duties as an effective fire and rescue service in the face of a catastrophic event such as the fire at grenfell tower there is an inevitable public interest
01:34:50 there is an inevitable public interest in scrutinized scrutinizing what actually happened 72 lives were lost families scarred forever and the lives of an entire community irreversibly
01:35:03 of an entire community irreversibly changed
01:35:04 changed it is an undeniable consequence of the fire at grenfell that our clients the grenfell community we as londoners and the british public are expecting the truth into what actually happened
01:35:17 truth into what actually happened why did things go wrong what are the factors that cause a contributor to the failings there must be accountability in order for lessons to be learned for there to be meaningful change and to ensure that
01:35:30 be meaningful change and to ensure that such a catastrophe is not repeated
01:35:35 regrettably all too often public officers and the managers and controlling minds of private organizations who make money out of activities which cast responsibilities on them for
01:35:47 which cast responsibilities on them for public safety fail to act with candor and act in their own narrow interests and those of their organization sometimes direct lies are told
01:36:00 sometimes direct lies are told sometimes the facts are manipulated sometimes emissions are made which impede the search for truth in this country and no doubt many other when things go wrong
01:36:13 when things go wrong and there are official investigations there is a culture of denial and a pervasive institutional defensiveness regrettably the lfb's response to this
01:36:26 regrettably the lfb's response to this inquiry has perpetuated a culture of denial
01:36:29 denial and persuasive institutional defensiveness
01:36:35 you know the experiences of the hillsborough families waiting for 25 years for accountability which came in part through the conclusion in the inquest in 2016
01:36:48 conclusion in the inquest in 2016 and which was sadly too late for some of the families was a watershed moment in british history
01:36:55 history never again should families be taken through the mill of observation and the denial of truth by public authorities this led to the tabling of the public
01:37:06 this led to the tabling of the public authority's accountability bill also referred to as hillsborough's law which calls for statutory duty of canada by public authorities in summary the public account authority
01:37:18 the public account authority accountability bill provides as follows a to set up a requirement on public institutions public servants and officials and those who are carrying out functions on their behalf to act in the
01:37:30 functions on their behalf to act in the public interest with candor and frankness
01:37:33 frankness b
01:37:34 b to define the public law duty on them to assist the courts official inquiries and investigations c
01:37:43 c to enable victims to enforce such duties d to create offences for breaches of certain duties and e to provide funding for victims and their relatives in
01:37:54 for victims and their relatives in certain proceedings before court and that official inquiries and investigations for and for connected purposes
01:38:02 purposes what's that got to do with all of this well
01:38:05 well our clients support the call for a statutory duty of candle a set out in the public authority's accountability bill
01:38:13 bill which we invite the panel to support in its recommendations you will have read the powerful words of our client adele chow we in our written submissions
01:38:26 adele chow we in our written submissions which we we will repeat as a renewal for the public call for accountability bill to be enacted into law and let me quote from adele
01:38:38 i just want to start with how grenfell differs from hillsborough unlike the struggle faced by the hillsborough families the
01:38:49 faced by the hillsborough families the very public and shocking image of a residential tower in the very center of our nation's capital meant that after an initial period of shock and inaction by central government a decision was made
01:39:02 government a decision was made to grant the grenfell families exceptional legal funding which during our inquiry has enabled our legal representatives first time round
01:39:13 legal representatives first time round to shine a light on the phalens this is a huge contrast to the decades-long fight experienced by the families at hillsborough and others
01:39:24 families at hillsborough and others we're our experiences match other families
01:39:29 families is a complete lack of candor we still see those bodies defending the indefensible rather than cutting their losses
01:39:37 losses the amount of amnesia we've seen even undeclared evidence being discovered during the course of the inquiry shows that the finely tuned structure of justice in the uk
01:39:49 justice in the uk is simply not balanced fairly between everyday victims and what are effectively much richer suspects or even perpetrators responsible for the deaths of their loved ones
01:40:01 of their loved ones we are very aware of the risks that any absence of candor has on holding people accountable for the deaths of our loved ones
01:40:11 ones but parity of arms and freedom of information doesn't extend to private bodies like arconic celetex
01:40:20 celetex kingspan or ryden who despite daming evidence remain bullish demanding evidential protection against prosecution and in some cases even refusing to give evidence
01:40:32 refusing to give evidence for us
01:40:33 for us this is a key part of the proposed hillsborough law if you're happy to accept and profit from taxpayer public money you must accept the same public body
01:40:45 accept the same public body responsibility and accountability when companies defend an indefensible position simply because they can spend their way out of accountability it causes years of pain and suffering to
01:40:58 causes years of pain and suffering to generations still fighting for their ancestors
01:41:02 ancestors and a huge cost to the taxpayer end quote
01:41:10 let me turn now if i may to the fire officers association and their submissions i've spoken at length in these
01:41:21 i've spoken at length in these submissions about the duty of canada at the heart of this call for this is recognition of the problem a lack of accountability by public bodies a closing of ranks
01:41:33 bodies a closing of ranks and the all too prevalent danger of such behavior leading to a repetition of past failures and wrongdoing this is endemic within many public bodies
01:41:43 bodies in this country in this inquiry this is not just found in the lfb we charge
01:41:50 charge rbkc and the tmo and most vermont some corporate cps from the construction industry with a culture of denial and institutional
01:42:01 of denial and institutional defensiveness it's worth just reminding ourselves of the words of the right reverend james jones kbe the former bishop of liverpool and the chair of hillsborough independent panel writing in november
01:42:13 independent panel writing in november 2017 in his report quote the patronizing disposition of unaccountable power a report to ensure the pain and
01:42:24 a report to ensure the pain and suffering of the hillsborough families is not
01:42:26 is not repeated the hillsborough families are not the only ones who have suffered from the patronizing disposition of unaccountable power the families know that they are others
01:42:38 the families know that they are others there are others who have found that when
01:42:40 when in all innocence and with good conscience they have asked questions of those in authority on behalf of those they love
01:42:48 they love the institutions have closed ranks refused to disclose information used public money to defend its interests and acted in a way that was both intimidating and oppressive and so the hillsborough
01:43:00 oppressive and so the hillsborough family struggled to gain justice for the 96 as a vicarious quality to it so that whatever they can achieve and call into account those in authority is of value to the whole nation
01:43:13 to the whole nation if greater illustration were required for the urgency of the public authority accountability bill one needn't look no further than the closing submissions filed on behalf of the fire officers
01:43:25 filed on behalf of the fire officers association whilst brevity and conciseness are often to be admired in legal documents the 19 pages provided by the foa
01:43:38 the 19 pages provided by the foa tells this inquiry all it needs to know about how little regard the fire officers association have for the extremely trenchant criticisms that have
01:43:49 extremely trenchant criticisms that have come their way from the experts from the families the bsrs the expert witnesses further their understanding of the performance of their own witnesses seems
01:44:02 performance of their own witnesses seems very much removed from the reality that the rest of us saw on its website on the foa's website it states quote foa membership is open to all uk fire
01:44:15 foa membership is open to all uk fire and rescue service staff and workers in the fire and rescue related roles in other industries the association provides individual and collective representation to members locally and at
01:44:26 representation to members locally and at a national level we represent the frs uniform middle management roles through membership of the middle management negotiating body of the national joint council for uk fire and rescue services
01:44:40 council for uk fire and rescue services no portion of any members subscription goes to a political party or was used for political purposes our members interests come first and we believe that these are best served through constructive consultation and
01:44:52 through constructive consultation and negotiation rather than traditional trade union muscle flexing in this way we can play constructive role in the changes that are uninevitable sorry that are inevitably taking place
01:45:04 sorry that are inevitably taking place within the service if confrontation is not is at the forefront of any agenda role progress cannot be made and benefits will not materialize end quote
01:45:15 benefits will not materialize end quote submissions filed on their behalf are in equal parts surprising disappointing and insulting
01:45:24 the opening gambit of its 19 pages is entirely self-serving there is absolutely no recognition of what module 5 and 6 sought to
01:45:36 what module 5 and 6 sought to investigate there is no ownership of any failings on their part no acknowledgement of the lack of recommendations at all of course the foa
01:45:47 recommendations at all of course the foa members did not cause a fire but that is an obvious remark but it fails to recognize the purpose and scope of modules five and 6. the lfb as an organization played a key
01:46:00 the lfb as an organization played a key and vital role on that night of the fire and was found wanting that is a state of affairs that should worry an alarm that any fire and rescue service which leads me to the next point
01:46:13 service which leads me to the next point where is the learning there is no self sense of self analysis in the document what shines through is institutional defensiveness
01:46:24 defensiveness the foa's closing submissions stay at paragraph 12 quote the fire at grenfell tower was an all-together different nature from any other fire lfb officers including rw had
01:46:37 other fire lfb officers including rw had ever experienced the speed and ferocity of the spread made it unique senior officers including rw had received no training that would have that would have or did equip them to
01:46:49 that would have or did equip them to manage the enormity of the challenges caused by the fire resulting in a wholesale failure of those who refurbished the tower to do so lawfully and safely end quote
01:47:00 and safely end quote this is very much in line with the mantra pedal by dan daly the former head of fire safety who remains assistant commissioner who gave evidence to the inquiry on the 30th of september
01:47:12 30th of september of last year the inquiry was shown the lfb's presentation titled entitled tall buildings facades dated july 2016
01:47:25 tall buildings facades dated july 2016 in which a slide label general conclusion referred to the need to understand products being used in facade systems and their fire behavior as well
01:47:36 systems and their fire behavior as well as if they are used appropriately and meet the need of relevant guidance the slides further added these could affect the way fires develop and spread in the building
01:47:48 building it is astonishing that none of the operational fire fighters who gave evidence to the inquiry in phase one had seen this presentation further it was never distributed to the
01:47:59 further it was never distributed to the most operational lfb staff including instant commanders and control room staff
01:48:07 staff pressed
01:48:08 pressed on why watch managers were not made aware of these conclusions mr daley argued that the presentation was quote
01:48:17 was quote more document that reassured that the regulations were there to do their job end quote he added quote i think what we witnessed at grenfell is something very
01:48:28 witnessed at grenfell is something very very different to our what our experience and exposure was at the time
01:48:34 our clients listened to the evidence and read the words of the foa's closing submissions with disbelief the foa seemed to inhabit a parallel
01:48:46 the foa seemed to inhabit a parallel universe in which well-publicized cladding fires around the world did not happen jonathan
01:48:54 jonathan sakula given evidence earlier to this inquiry said that the combustibility of building systems similar to that used in grenfell tower were well known mr sakula highlighted several fires that
01:49:06 mr sakula highlighted several fires that were propagated by aluminium composite materials cladding and polyurethane core the same combustion that caused the fire to spread at grenfell tower where 72
01:49:17 to spread at grenfell tower where 72 people were killed some of the fires listed in a report he prepared for the inquiry included the 2013 al
01:49:30 in the united arab arab era emirates the 2015
01:49:35 2015 um fire at the 60 um three-story address hotel in
01:49:40 hotel in dubai and one in ramadan israel in 2016. no fatalities were reported with the two two of these fires with one death at the address hotel incident
01:49:53 address hotel incident but in their parallel universe presumably the foa did not take note of the clad and fires in this country as well
01:50:03 well the bbc's program five fires that foretold grenfell makes for chillin viewing
01:50:11 viewing the program explores the causes subsequent investigations and the recommendations that were sent to successive uk governments the five fires revisited
01:50:22 revisited included summer summerland disaster on douglas in the isle of man 1973 the noseley height fire in liverpool in
01:50:33 the noseley height fire in liverpool in 1991
01:50:34 1991 the garnok caught fire in um north airship in 1999 the harrow court fire in stevenage in 2005 and lachanol in
01:50:46 in stevenage in 2005 and lachanol in 2009
01:50:49 2009 the inquiry was also shown a slideshow prepared by kevin hughes the fb head of engine fire engineer and specialist fire safety to be delivered at a tall buildings conference in london in june
01:51:02 buildings conference in london in june 2017 a week after grenfell he sent his presentation to colleagues for comment with speaker notes in draft form in may 2017
01:51:14 form in may 2017 asking for feedback his notes stated that quote flammable building facades are a common challenge for the lfb in residential buildings the
01:51:25 for the lfb in residential buildings the fire is not confined to the flat of origin and our staple limited evacuation strategy is compromised mr hughes further wrote large-scale evacuations in residential
01:51:37 large-scale evacuations in residential buildings especially those with single staircases cause a problem in terms of staircase capacity and obstruction to firefighters the reason for highlighting this is to raise awareness of the
01:51:48 this is to raise awareness of the problem i believe that the codes and firefight fire engineering principles we use to design fire safety into buildings are excellent but facade fires an uncontrolled spread of fire across the
01:51:59 uncontrolled spread of fire across the outside of tall building is a significant threat to the effectiveness of many systems within the buildings they knew
01:52:12 the subsequent exchange between dan daly and mr millet of queen's council it was illuminating mr miller
01:52:24 mr miller some people may regard the timing of what i've just read to you as prophetic in many ways but my question for you is is what i've just read to you not considering not considered to be something that all what watch managers
01:52:37 something that all what watch managers who are going to be likely to be attending as first responders at high-rise spies in london should have known
01:52:42 known answer i think when you look at the words here i completely agree that an outcome that you'd like to see i think
01:52:51 i think as the lead for fire safety i would have been looking to evidence examples of what of that and to put in place appropriate awareness packages question
01:53:02 question would you agree that here is a clear indication that the fire safety department was aware before grenfell fire
01:53:11 fire that a staple strategy may not be suitable for high-rise block which has non-compliant cladding answer i would say that my cert i would say that certainly my opinion at the
01:53:22 say that certainly my opinion at the time was that staple is absolutely incumbent on compartmentation working that if
01:53:28 that if we were to have an example of those compartments could be overwhelmed or overrun then that would compromise stay put mr daley accepted that he was
01:53:41 mr daley accepted that he was quote not sure we've always taken every opportunity to learn as an organization end quote
01:53:48 end quote protection wasn't always as high up on the agenda as it needed to be and so opportunities to learn from protection haven't always been as well addressed i think were better now
01:54:02 think were better now mr daley was also asked about the fire at uh
01:54:05 at uh madeline house in kingston in 2010 a consultant's report following the five found that multiple materials used in maddening house external facade quote
01:54:16 maddening house external facade quote had no resistance to ignition and spread flame producing large volumes of dense black smoke following on from the fire in an email
01:54:27 following on from the fire in an email one lfb fire engineer discussed the possibility of recommending that early evacuation of the building should be considered at madeline house three sister blocks in the event of a future
01:54:39 sister blocks in the event of a future fire asked by mr miller of queen's council question to the madeleine fire you would accept as a good example of learning of a learning event for the lfb where no learning or insufficient
01:54:50 where no learning or insufficient learning was taken answer i don't know that no learning was done but as an officer in the brigade at the time i should have known about something related to this fire from what you have
01:55:01 related to this fire from what you have demonstrated and i wasn't aware of until today
01:55:07 at grenfell towers dr lane opined we saw total building failure and the fire in terms of its ferocity and speed and spread were indeed
01:55:18 and speed and spread were indeed something that those presents had never personally experienced before but they did and should have had firstly the knowledge and training to enable them to identify grenfell as a
01:55:29 enable them to identify grenfell as a captain buyer and therefore been equipped to be cognizant of all that comes with such a fire secondly they should have had or been
01:55:40 secondly they should have had or been aware that and been better prepared in terms of their firefighting strategy they should have had an understanding of the potential for compartmentation failure and they should have been ready
01:55:52 failure and they should have been ready with contingencies including evacuation planning
01:55:58 planning the bold assertion at paragraph 12 of the foa statement is disingenuous and fails to acknowledge any failings on the
01:56:09 fails to acknowledge any failings on the part of the f l f b
01:56:14 l f b staple
01:56:15 staple national guidance requires fire and rescue service to drop contingency evacuation plans for dealing with fires and high-rise buildings that spread beyond the compartment of origin causing a staple strategy to become untenable
01:56:29 a staple strategy to become untenable the lfb's policy for fighting fires in high-rise buildings that's pn 633 envisages that evacuation of a high-rise building residential building may be necessary and suggest that during
01:56:42 may be necessary and suggest that during familiarization visits officers should consider evacuation arrangements so let me turn to richard welsh the impression given by the foa
01:56:55 the impression given by the foa submissions characterized richard welsh as a bemused bystander looking on in shock and awe at the horror blaze unfolding before his eyes that night
01:57:06 eyes that night it's almost as if the foa wished to cast him in the same light as the residents and onlookers from the surrounding estates who did look on with a scent total sense of
01:57:18 look on with a scent total sense of impotence unable to fathom with what their eyes were seen unable to do anything to stop the blaze or to help the residents but such a comparison between mr welch
01:57:30 but such a comparison between mr welch and the residents or onlookers is both insulting and wholly wrong mr welsh and the other senior officers who attended were not mere bystanders
01:57:41 who attended were not mere bystanders they were professionals they were individuals who should have known and who should have been aware or who should have been sufficiently trained
01:57:52 trained evacuation planning the adherence to state port and the presumption that compartmentation was a fail-safe measure meant that the lfb did not even contemplate evacuation planning
01:58:05 not even contemplate evacuation planning or strategies for grenfell tower evacuation plans cannot be done on the hoof
01:58:11 hoof they require pre-planning that then takes us back to the foundations of lfb policies namely section 72d whatever assumption or presumptions the
01:58:23 whatever assumption or presumptions the foa
01:58:25 foa or richard welsh relied upon the compartmentation breach of mr kabedi's flat was a first and early sign that matters were not going to follow
01:58:36 matters were not going to follow assumptions and presumptions that night the fire spread was the second the sad reality is as found by the chair in phase one
01:58:49 the foa asking you sir to revisit your phase one report let me turn to that
01:58:56 the phase one report and the executive summary sir you found that the lfb to be gravely inadequate concerning
01:59:07 concerning instant command and the senior officers lack of training read the dangers associated with combustible cladding incident command training no evacuation contingency planning
01:59:18 no evacuation contingency planning ord contained little or no relevant information of the use to the incident commanders basic information held about the town was wrong
01:59:30 in the light of those findings the f um uh the fire uh officers association submission state at pagar 53 quote in these circumstances the learner
01:59:43 in these circumstances the learner chairman or respectfully to revisit his findings in this regard in his phase one report
01:59:52 this closing statement is as astonishing and
01:59:57 and audacious
01:59:58 audacious as their opening one and returns the foa to their alternative reality
02:00:04 reality it shows a cavalier disregard for the work and investigation of the inquiry thus far
02:00:11 thus far and moreover we say shows contempt for the bsrs and the memories of their loved ones who lost their lives on that night the close and submissions of the fire officers association the london fire
02:00:22 officers association the london fire commissioners taken together make a mockery of accountability and reflects badly on the semblance of accountability for the lfb
02:00:33 semblance of accountability for the lfb the fire the london fire commissioner's response the london the london commissioners have on the one hand in their written submissions reminded the inquiry of the commissioner's evidence quote large organizations must always
02:00:45 quote large organizations must always develop policy and procedure through learning from experience and that culture must be embedded and never-ending expressing his determination to ensure that london fire brigade is proactive in its approach
02:00:57 brigade is proactive in its approach particularly with regard to the increasing complexity of modern construction design methods and materials insofar as they impact on fire safety end quote this is of course
02:01:08 this is of course contrasted on the other hand with the fire officers associations call for the inquiry to revisit its phase one findings of the um
02:01:19 findings of the um lfb's failures on on the night we are left questioning the express calendar of the lfb in the london chief commissioners written submissions at paragraph seven
02:01:30 written submissions at paragraph seven and eight
02:01:31 and eight from which we highlight quote in short the lfc's fully acknowledges responsibility for the brigade's operational response to the grenfell tyre fire and is firmly
02:01:42 grenfell tyre fire and is firmly committed to ensuring wherever possible that lessons which must be learned are acted upon robustly it begs this question is this the same organization
02:01:56 is this the same organization whilst we do not challenge the integrity and the commitment of individual firefighters the contrasting submissions of the
02:02:06 of the lfc and the foa place a stop light on the culture of institutional defensiveness of the lfc and an unwillingness to change
02:02:18 to change where the words of the commissioners become just mere lip service
02:02:25 not withstanding the lfc's purported commitment to candor the commissioners acknowledgment of the known risk of cladding fires it is of note that the lfc's response to the lfb's failure to
02:02:38 lfc's response to the lfb's failure to have considered the effectiveness of evacuation at night or or the absence of the evacuation policy c paragraph 82 of the lfc submissions has the hallmarks of
02:02:51 the lfc submissions has the hallmarks of institutional defensiveness which in ever invariably impacts on the implementation of meaningful change you see what's needed is this
02:03:02 you see what's needed is this the establishment of an independent operational assurance advisor reporting to the lfc that's a positive step towards the
02:03:13 that's a positive step towards the assurance of oversight its success is wholly dependent on the collective commitment of the institution of the lfb
02:03:25 of the lfb the foa's closing statements do not imbue confidence in such a commitment the stark contrast between the foas
02:03:36 the stark contrast between the foas and the lfc submissions underscores the problems and the difficulties we identify for mr rowe how can he reconcile these
02:03:47 how can he reconcile these differing
02:03:49 differing stances
02:03:50 stances how can the inquiry be satisfied that the lfb as an organization will accept and act upon any failings which are found in phase two
02:04:02 the changes implemented since grenfell we of course welcome the changes that have been implemented by the lfb since grenfell and in particular we
02:04:14 lfb since grenfell and in particular we welcome the use of the sticks fire escape hoods smoke blockers the new term table appliance drone capabilities which provide situational awareness to
02:04:26 which provide situational awareness to instant commanders to aid decisions making and capability of smaller drones to be fitted with loud speakers for broadcasting public messages and may i
02:04:37 broadcasting public messages and may i add and i add this particularly in relation to uh my client nabil um who lost his family six members of his family you know he he would wish me to make the point that
02:04:49 would wish me to make the point that it's really important that this new technology you know proper camera system time stamp recordings um the speaker system that can actually be um heard that the systems actually work
02:05:04 um heard that the systems actually work in the event of a serious fire we note
02:05:08 we note uh the revisions of policies to address the deficiencies in high-rise firefighting evacuation and fire survival guidance which all purport to address the lfb's deficiencies borne out
02:05:20 address the lfb's deficiencies borne out in its response to grenfell we are sure and it's that it's not lost on the panel and indeed the inquiry team that the lfb is awash with policies arguably there's a policy for every day of the year but
02:05:33 a policy for every day of the year but as we can all acknowledge from this evidence we heard in phase one and modules five and six there have been serious inadequate inadequacies in the training of operational firefighters on policy and
02:05:45 operational firefighters on policy and the operation of equipment the reported revision of the control room and the rolling out of technology is as good as the resource in an upgrading of technology to ensure that
02:05:57 upgrading of technology to ensure that it works and equipping the control staff with adequate training to use the resources at hand less the fsg apps will be beleaguered with the same fate as the cu equipment
02:06:11 with the same fate as the cu equipment which we heard in phase one which never worked it's really important that if you've got the technology make sure it works we're equally concerned that notwithstanding the acknowledged failing
02:06:22 notwithstanding the acknowledged failing of the barrie radios at grenfell which was a well-known fact in the lfb barrie radios are still being used by operational firefighters
02:06:34 let me turn to the fbu submissions the f
02:06:40 the f bu submissions in in contrast does seem to dwell in the same reality as the rest of us there is some reflection and acceptance and provide important context and
02:06:52 and provide important context and analysis with regards to the issue of industrial action and any alleged correlation between that and the failures to implement lack of recommendations training and the socio-political climate
02:07:06 training and the socio-political climate the leadership under mr dobson failed and its rank and file members and it failed it failed its rank and filed members and it failed londoners he and others at the very top of the organization acquiesced rather than take
02:07:19 organization acquiesced rather than take on johnson we wholeheartedly agree with the fbu's closing submissions at paragraphs four to six the individual private companies did create an unsafe
02:07:30 private companies did create an unsafe building we have been forceful and consistent in our criticism of the lfb and the firefighting operation on the night and what we described as the systemic failings of the organization
02:07:42 systemic failings of the organization but as noted in the fbu submissions at paragraph four whatever the weakness and indeed the failings of the lfb on the 14th of june there can be little doubt that the disaster was caused by a
02:07:53 that the disaster was caused by a combination of significant failings by individual private companies in pursuit of profit above all and a generation of policies by central government including deregulation the
02:08:05 government including deregulation the war on the culture of health and safety privatization historic austerity and cuts of public services including the frs and the decrease in the
02:08:17 frs and the decrease in the degradation of social housing city hall
02:08:22 city hall under the leadership of the then mayor of london boris johnson was ruthless in the pursuit of cuts and the frs was not exempt from the acts we do maintain that the culture of the
02:08:35 we do maintain that the culture of the lfb
02:08:36 lfb as an organization has acted as a barrier to effective change and has led to institutional defensiveness we look more at the evidence of a witness such as rita dexter rita dexter was aware of
02:08:49 as rita dexter rita dexter was aware of the quality and nature of the 72d visits was variable and therefore systemic and long-standing systemic failure she attributes much of this to the ingrained attitude and behavior down to
02:09:01 ingrained attitude and behavior down to the culture of the lfb it was a culture that was resistant to change the corollary of what was things that required urgent attention rectification which were allowed to continue
02:09:12 which were allowed to continue deteriorate and stagnate training and knowledge it's true that the fbu had warned about claddon for many years and consequence of the and
02:09:23 many years and consequence of the and the consequences of cladding fires and it's a tragedy that the wide organization did not listen to the fbu this is where training is so important we have consistently stated that the
02:09:34 we have consistently stated that the inquiry needs to examine the role of babcock and training that they provided we welcome and endorse the submissions in relation to training by the fbu at
02:09:45 in relation to training by the fbu at sections uh at paragraph 72 to 74 of their submissions there is an acknowledgement by the fbu that there were failings and again we agree and endorse the submissions at paragraph 75
02:09:57 endorse the submissions at paragraph 75 through to 99 in relation to the failure of the senior leadership of the organization to transfer knowledge and information throughout the organization complacency of leadership the failure of
02:10:08 complacency of leadership the failure of leadership to consider that a fire such as grenfell could happen outsourcing of training to babcock and the role of former commissioner dobson austerity and cuts
02:10:20 commissioner dobson austerity and cuts we are in line with the fbu on those points
02:10:25 points let me turn now to the national oversight mechanism the continued failure of public authorities to implement inquiry recommendations and prevent and
02:10:36 inquiry recommendations and prevent and prevent
02:10:37 prevent prevention of further deaths reports arising from inquests as we've seen from the lfb's treatment of the coroner's rule 43 recommendations
02:10:50 of the coroner's rule 43 recommendations places this inquiry's recommendations to suffer a similar fate in the absence of a independent body charged with the implementation of your recommendations
02:11:01 implementation of your recommendations we are likely to hear further evidence in module 7 from experts on the formidable challenges faced by those seeking to secure meaningful change after a tragedy like grenfell fire
02:11:13 like grenfell fire evidence that may help us understand why the recommendations from lacanal were not implemented and why without a national oversight mechanism coupled with a duty of candor it is not
02:11:24 coupled with a duty of candor it is not just a risk but likely reality that any changes recommended by you risk suffering the same fate as the recommendations from lachnal more lives
02:11:35 recommendations from lachnal more lives will be lost the 72 will have died in vain accordingly sir we invite this inquiry to adopt the recommendations of inquest for the
02:11:46 recommendations of inquest for the establishment of a national oversight mechanism which is an independent body with the duty to collate analyze and monitor and currently and disparate hard
02:11:57 monitor and currently and disparate hard to access and locally held recommendations of coroners and other post-death investigations and inquiries which was adopted by the recommendations of the justice working party when things
02:12:09 of the justice working party when things go wrong
02:12:11 go wrong the rationale behind this is to ensure compliance after you make your recommendations i remind the panel during our module 6 opening statement of nicholas
02:12:22 opening statement of nicholas burton's evidence and his plea for accountability which in the light of the lfb's demonstrable lack of candor is worth repeating if only to remind the public authorities including the lfb
02:12:34 public authorities including the lfb rbkc tmo and dclg that their decisions and consequential outcomes affect real lives the breed
02:12:45 outcomes affect real lives the breed survivors residents for whom justice without truth and accountability is just a fleeting illusion to be pursued but will never be attained an act an extract from nicholas burton's
02:12:57 an act an extract from nicholas burton's evidence is quote
02:13:00 quote the consciousness of the nation is looking at us all how this inquiry how the police investigation is going but this is so important that it has to
02:13:13 but this is so important that it has to stop here
02:13:14 stop here we've seen failings and failings i've been failed so many times and failings with other fires and other lessons not learned so grenfell has to
02:13:26 lessons not learned so grenfell has to stand for something and it's got to stop here about how people are treated and how loopholes in the systems need to be closed
02:13:36 closed a response observation lack of candle refused to accept this inquiry's findings as the fire officers association submissions indicate
02:13:47 submissions indicate perpetuates these failings this reinforces the need for a statutory duty of candor and a national oversight mechanism
02:13:59 mechanism i finish
02:14:01 i finish where i started the one message that this inquiry can powerfully send out to the lfb is this
02:14:13 are meant for learning not repeating thank you
02:14:20 thank you well thank you very much
02:14:23 the next statement is going to be made in a moment by mr brown queen's council he's going to make his statement from a remote location and we're going to have a
02:14:34 location and we're going to have a five-minute break at this point just to make sure that we've established all the communications so we'll rise for five minutes we'll resume at 20 past 12 please and we shall hear mr brown thank
02:14:45 please and we shall hear mr brown thank you
02:20:55 now the next statement is going to be made by mr brown queen's council on behalf of the fire officers association and mr welch so the first thing to do is to make sure that we can see and hear each other good
02:21:07 that we can see and hear each other good morning mr brown good morning to you sir and you can see me and hear me i hope i can thank you thank you and we can see you so when you're ready um please make
02:21:18 you so when you're ready um please make your statement thank you very much mr chairman can i begin by making some brief observations please before turning to the submissions themselves
02:21:29 to the submissions themselves and firstly um we were very sorry that our closing submissions for these modules have caused the upset expressed by professor thomas queen's council
02:21:40 queen's council in his submissions you will know sir that we have during our participation inquiry frequently expressed our sincere sympathy
02:21:51 sympathy and condolences to the bereaved survivors in residence for the losses they suffered as a result of this appalling tragedy and nothing that i say on behalf of those who instruct me or clients should
02:22:02 those who instruct me or clients should be taken as in any way diminishing those condolences and sympathy secondly
02:22:10 secondly mr welsh was motivated purely by a desire to save lives of the residents who were in the tower that night and we don't in any way seek to put him
02:22:21 and we don't in any way seek to put him in the same position as the resident in the tower he was of course a professional firefighter and should be treated as such however
02:22:31 however his actions should not be treated with the benefits of hindsight but should be assessed with the benefit of the knowledge that he had or reasonably to have had on the night
02:22:42 and finally this where there are lessons to be learned as a result of your findings both in phase one and phase two they will and must be learned
02:22:53 learned so having made those uh i hope helpful introductory comments and can i then begin with our submissions we begin by asking the question where does the real failure
02:23:05 does the real failure for the fire and deaths of grenfell tower lie
02:23:10 tower lie and we maintain the position respectfully that it is easier to begin by stating where it does not lie it does not lie with the individual lfb officers and staff who tried heroically
02:23:21 officers and staff who tried heroically to quell the fire and rescue as many lives as possible on the night of the fire critical and crucial decisions were made by lfp officers and staff on the assumption
02:23:32 officers and staff on the assumption an entirely reasonable assumption we respectfully submit that the provisions of the building regulations and approved document b would fit for purpose and had been complied with they clearly were not and
02:23:44 complied with they clearly were not and central government should have known they were not we agree with and respectfully adopt the submissions of the fbu and its opening submissions for these modules on the failure of successive governments in
02:23:55 failure of successive governments in this regard further we agree with and adopt the submissions made on behalf of the mayor of london in his opening submissions for these modules as to the failures and the consequences of those failures of
02:24:07 consequences of those failures of central government particularly failures to take any or any effective action to implement rule 43 recommendations after the fire at black and all house
02:24:18 after the fire at black and all house but shortly had central government complied with its duties of regulation and enforcement had the manufactures of the cladding and its composite parts complied with their implicit duty of good faith to supply
02:24:29 implicit duty of good faith to supply materials for certification which met regulatory requirements and had building control properly discharged his duty to ensure compliance with regulations including issues as to design safety
02:24:40 including issues as to design safety then the cladding it installed at grenfell tower would not have been authorized and installed in which case they fire up such catastrophic proportions with such devastating loss of life would not have occurred
02:24:53 of life would not have occurred can i then turn please to consider the preparedness of lfb office and staff to deal with the fire at grenfell tower and the enormity of the challenges posed by it
02:25:04 by it in his oral evidence lfb commissioner former commissioner ron dobson said i wish we'd taken a number of actions in relation to the evacuation of high-rise buildings
02:25:15 buildings but as i explained to you yesterday whilst it was at risk whilst we knew evacuation did take place it was difficult to identify what the steps would be that you would tell
02:25:26 steps would be that you would tell firefighters to take to actually manage a full evacuation in a residential high-rise building where there was no central fire alarm and no record of who was in the building or not
02:25:37 was in the building or not he was asked was there a need to ensure that operational firefighters indeed officers of all right were better aware of the limitations to stay put and had considered the prospect of evacuation in
02:25:48 considered the prospect of evacuation in a high-rise residential building should the need arise and he answered yes in his oral evidence a commissioner rome said this about lfp training on the risk of cladding fires
02:26:01 training on the risk of cladding fires i think this was about how we dealt with a specific risk that was known to one part of the organization but hadn't necessarily been effectively communicated to another part of the organization
02:26:12 organization we knew about the possibility of exterior cladding fire but we hadn't communicated it effectively internally on the issue of widespread complementation failure leading to the untellable untenability
02:26:24 leading to the untellable untenability of stay put commissioner rose said this i think what we didn't do enough for our officers and crews was actually to prepare them for how they might deal with that situation should it confront them
02:26:35 them that didn't translate into training as to how you might address it further
02:26:41 further what i would hold to this day is that the totality the scale and the extremity of the failure of every single part of regulation and human behavior that should underpin it would have been difficult to predict
02:26:54 it would have been difficult to predict i think what caught people by utter surprise
02:26:57 surprise and i would include myself in the first few moments of the grenfell town fire was just the totality of it it seemed almost unbelievable to me that we would lose an entire residential block
02:27:08 would lose an entire residential block in modern britain you know it still shocked me to this day because i think it says something about all the systems and institutions that should have kept those people safe we had not conceived the scale of
02:27:20 we had not conceived the scale of failure that we encountered at brentford it seems almost unimaginable to me i'm not sure that at this point if we were planning a response we would have planned for the totality
02:27:31 we would have planned for the totality of that failure however we should still have prepared our people for what they might do if they did experience something on that scale the commissioner rightly in our
02:27:42 the commissioner rightly in our respectful submission said this i would go back to the point that at the point people arrived at that incident the speed with which the fire developed the extremity of it and the totality of the failure made everything
02:27:54 totality of the failure made everything extremely difficult in terms of decision making so i have real sympathy for the officers who arrived at that incident in the early stages because it would i imagine i felt overwhelming in terms of
02:28:05 imagine i felt overwhelming in terms of the scale and the rapidity of the fire spread and the unusual nature by which it was spreading although
02:28:13 although this was criticized it is correct that the fire at grenfell towers of an altogether different nature from any other fire lfb officers including mr welsh had ever experienced
02:28:24 welsh had ever experienced the speed and ferocity of a spread made it unique
02:28:28 it unique in their experience senior officers including mr welsh had received no training that would have or did equip them to manage the enormity of the challenges caused by a fire resulting from a
02:28:40 caused by a fire resulting from a wholesale failure of those who refurbished the tower to do so lawfully and safely and dr lane's opinion is we respectfully submit cogens
02:28:52 submit cogens based upon the relevant test evidence the construction materials forming the rain screen cladding when considered either individually or as an assembly did not comply with the recommended fire performance
02:29:03 performance in the approved document b the entire system could not adequately resist the spread of fire over the walls having regard to height use and position
02:29:14 having regard to height use and position of the building specifically the assembly failed adequately to resist the spread of fire to an extent that supported the required stay put strategy for grenfell tower the assembly failed adequately to resist
02:29:26 the assembly failed adequately to resist the spread of fire to an extent that supported the required internal and firefighting defend in place regime the cladding presented an extreme and primary hazard
02:29:38 primary hazard in the event of any internal fire starting near the window there was a disproportionately high probability of fire spread into the rain screen cladding system the type of materials in the rain screen
02:29:49 the type of materials in the rain screen cladding and how they were arranged around the window in the kitchen contributed to the speed in which the fire spread from the flat of origin to a multi-storey external fire within the
02:30:00 multi-storey external fire within the rain screen system a full geometric grid was created by means of the construction materials which connected in the event of an internal fire cavity fire or external fire every flat
02:30:13 cavity fire or external fire every flat on a story and every story from level two to roof level these pathways also supported the spread of external fire back into the building through the windows and created a series
02:30:24 through the windows and created a series of internal fire events the consequence of this was that any individual flat of fire origin was no longer in a separate fire rated box as required
02:30:35 box as required the compartmentation required in the building was breached by the ability of the fire to spread on the external wall from that compartmented flat to the next and as she put it a building with this
02:30:46 and as she put it a building with this form of external wall could never provide the high degree of compartmentation required to support statehood
02:30:54 statehood professor bisby said that such a fire spread was inevitable the required single safety condition stay put was not provided for as was required
02:31:05 required as a result of the rain screen system installed during the refurbishment and grenfell tower should never have been handed over with this system where a state put strategy was in place
02:31:18 where a state put strategy was in place dr lane did not consider it reasonable that in the event of the installation of a combustible rain screen system on the high-rise residential building the fire brigade should be fully expected to
02:31:29 brigade should be fully expected to mitigate fully any resulting fire event that was particularly so where the brigade had never been informed that a combustible rain screen system had been installed
02:31:39 installed there are so many combinations of events that could fall entirely outside the reach of internal external firefighting activity this was and i quote important when only internal
02:31:50 and i quote important when only internal firefighting arrangements are made for high-rise residential buildings by statutory guidance at this time her overall conclusion was that there were multiple catastrophic fire routes
02:32:01 were multiple catastrophic fire routes created by the construction form and construction detailing that was used
02:32:06 used the cladding is configured at the tower rendered it unsuitable for staple policy once fire was within the cladding there was nothing to impede the spread of fire and smoke around the building and this
02:32:17 and smoke around the building and this created the conditions for a catastrophic fire event to occur as stated
02:32:23 as stated none of those matters were matters known to the lfb those taking command decisions on the night of the fire
02:32:32 as was noted by professor bisbee when he gave all evidence external firefighting was likely to have had little effect the single stair and lobbies and the fire safety provisions they're in were
02:32:43 fire safety provisions they're in were not ever designed to create a safe escape route or a safe working environment in a whole building fire the design approach for high-rise residential buildings is based upon
02:32:54 residential buildings is based upon inhibiting that from occurring
02:32:57 the net effect of all of this is that those lfb personnel taking command decisions on the night had no prior opportunity to consider their firefighting and rescue tactics as well as any evacuation guidance to residents
02:33:10 as any evacuation guidance to residents having regard to how the fire was likely to behave and spread once on the exterior of the building so as regards the non-compliance of the active and passive firefighting measures at the tower
02:33:22 at the tower but we respectfully refer to our closing submissions for phase one paragraphs 8-14 which we say respectfully remain entirely relevant and enforce when considering the issues relevant to
02:33:35 when considering the issues relevant to modules five and six in this phase what then of the recognition of the need to abandon stay put sooner the stay put strategy as defined by dr
02:33:46 the stay put strategy as defined by dr lane is as you know sir the concept of occupants and dwelling dwellings are joining the dwelling on fire being safe if they remain where they are as she pointed out stay put was a building safety condition
02:33:59 stay put was a building safety condition which relies on active and passive fire protection measures it had formed the basis of high-rise residential buildings fire safety guidance
02:34:08 guidance in the uk from 1971 since the stay put strategy was a building design condition the lfb officers in command reasonably relied upon this building design
02:34:20 relied upon this building design condition on the night of the fire there is no building design function in a high-rise residential building provided to enable firefighters in the uk to communicate any change in their
02:34:32 uk to communicate any change in their evacuation or rescue guidance from within the building that the state put strategy applied to grenfell tower at the time of the fire is clear
02:34:42 is clear the rbkc tmo ryden grenfell tower regeneration letter for july 2014 under the section emergency fire arrangements made it quite clear that
02:34:53 arrangements made it quite clear that the state stay put policy remained in force until residents were told otherwise
02:34:59 otherwise that was because and i quote grenfell was designed according to rigorous fire safety standards also the new front doors for each flat can withstand a fire for up to 30
02:35:10 can withstand a fire for up to 30 minutes close quotes forgive me which gives plenty of time for the fire brigade to arrive close quotes the stray put strategy requires compliance by the building owner with
02:35:21 compliance by the building owner with the active and passive and other fire protection measures within the high-rise residential building where a stay-put strategy is in place additional protection to the staircase should be provided in the form of a
02:35:33 should be provided in the form of a smoke control system external walls should be constructed using the material that does not support fire spread and therefore endanger people in or around the building
02:35:44 people in or around the building flames spread over or within an external wall construction should be controlled to avoid creating a route for rapid fire spread bypassing compartment floors or walls
02:35:56 or walls and combustible materials should not be used in cladding systems and extensive cavities
02:36:02 cavities what then did mr welsh need to know mr welsh and in fact other senior officers in the tower need to know re-abandoning stay put but did not know at the time
02:36:15 know at the time mr welsh had received no training that equipped him to appreciate why the fire at grenfell tower a was behaving as it was b
02:36:23 b that might be behaving in this way because there was external cladding in place which was constructed of materials that did not comply with building regulations c
02:36:33 c this required sufficient understanding of building construction fire engineering fire dynamics human behavior and how those factors interacted with each other against the backdrop of the actual fire itself and
02:36:45 backdrop of the actual fire itself and how it appeared to be behaving further that this may affect the viability of the state put policy and how if stay put was to be abandoned any evacuation attempt might viably be
02:36:58 any evacuation attempt might viably be achieved
02:36:59 achieved he and the other incident commanders would not have known what is now known namely that the cladding system contained insulation which was combustible that acm range screen panels contained a
02:37:11 that acm range screen panels contained a highly combustible polyethylene core and that the system did not comply with the functional requirements one of schedule wanted the regulations and the external walls of the building
02:37:22 and the external walls of the building did not resist and indeed actively promoted the spread of fire he and other incident commanders would not have known what is now known namely the fire entrance doors were not compliant with the building regulations
02:37:35 compliant with the building regulations 64 of flat entrance doors self-closing devices were either broken or misting the mounts master door door sets were not capable of achieving 30 minutes of
02:37:46 not capable of achieving 30 minutes of fire and smoke resistance and when tested by bre in february 2018 their integrity fell within 15 minutes it was inevitable that those factors
02:37:57 it was inevitable that those factors increased the speed and ferocity of internal fire and smoke spread as to the viability of a full evacuation it is a critical importance here to
02:38:08 it is a critical importance here to appreciate that there is still no national
02:38:10 national or local guidance as to how a viable evacuation could have been achieved and we will turn to this shortly as to mr welch's actions on the night as
02:38:21 as to mr welch's actions on the night as is known to say he was status three at 01.5720
02:38:25 01.5720 one
02:38:26 one on arrival a glimpse of the tower suggested that the east side of it was a light however he was unable to see at that time whether the fire had penetrated from the exterior back into the flats
02:38:37 the flats as the fire was by then at 25 pump fire and he was so he understood at the time the senior officer present he took over as i see
02:38:47 as i see he requested various messages to be sent and set out in our submissions at paragraph 27 and he explained his rationale for those mainly that life will always come first so the priority
02:38:59 will always come first so the priority was to get the people the decision as to the sufficiency of resources in particular edba wearers was one that he would consider when inside the tower
02:39:09 the tower so as being able at that point to obtain a better situation awareness of where we were what the aims were what our difficulties were at the point when he requested to make
02:39:20 at the point when he requested to make pumps 40 he still thought that the fire was on the exterior face he also took those steps set out in paragraph 31 of our submissions
02:39:31 of our submissions and at 32
02:39:33 and at 32 his strategy as i see was to reach fsg callers as quickly as possible and remove them from the building or get them to a safe place in the short time he was icy instant
02:39:45 in the short time he was icy instant commander he did not have thoughts that the stay put policy should be revoked or changed to an all-out in his oral evidence he explained his thinking
02:39:55 thinking he said i had no reason to think that the building complementation would be failing and that the fire would be spreading across that way because it's not something that we see the state put policy works time and time
02:40:06 the state put policy works time and time and time again so i believed in that policy
02:40:10 policy while he was on cu-8 he was informed by doc daco lachlan that d.a.c.o lockland was incident commander
02:40:19 commander mr welsh informed him of the messages that he had sent and d.o.c lachlan agreed with what he had done and indicated he would have sent the same messages he was given the role of fire sector
02:40:31 he was given the role of fire sector commander and in the case of grenfell tower the fire sector was the entire building
02:40:36 building from the point where mr welsh was uh incident
02:40:39 incident commander it would and should have been appreciated that he could not also have been acting as bulk media advisor once d.o.c lockland was appointed insulin commander it was then his responsibility to ensure the provision
02:40:51 responsibility to ensure the provision of an adequate water supply to the tower which is a fundamental function of incident command say for a very short period of time throughout the entirety of the relevant period
02:41:02 period mr welsh was inside the tower and the issue of the provision of inadequate water supply to the tower was not a matter which was his responsibility or over which he had any control
02:41:13 control as the remainder of his actions on the night and his rationale for them we respectfully adopt and repeat paragraphs 71 to 97 of our closing submissions for phase one
02:41:27 but mr welsh had considerable experience of fight fighting high-rise residential fires
02:41:33 fires but with that experience he would assume that grenfell tower as originally built appear to have been designed on the premise of providing very high levels of passive fire protection
02:41:44 passive fire protection turning then to mr mcgurk's reports while these were not matters he was asked to
02:41:50 asked to specifically address in his oral evidence the following are in our respectful submission of importance in his report section d alternative firefighting research and rescue statutes
02:42:01 statutes mr welsh
02:42:03 mr welsh referred to the kent fire and rescue sap as regards that rice
02:42:09 rice is simply a prompt or mnemonic it is not a policy or procedure and offers no practical advice on how a full or partial evacuation is to be achieved in any situation
02:42:21 to be achieved in any situation and certainly after o158 rice was of extremely limited relevance to the situation of the tower since in the initial stages of the fire which began on the fourth floor
02:42:32 began on the fourth floor eighty percent of the occupants were above the fire ground adopting the rice model floors five and six might have been considered primary areas needing to be evacuated due to imminent danger from
02:42:44 evacuated due to imminent danger from the fire
02:42:45 the fire however in the time required to evacuate those floors the speed and ferocity of fire spread was such that in the meantime
02:42:53 meantime many parts of the stairwell would have been compromised the core activity underlying rice the maintenance of the integrity of the means of escape was not achievable
02:43:04 means of escape was not achievable given the speed and ferocity of fire spread it would not have been possible to determine firstly how the various parts of the stove stairwell all subject to fluctuating conditions might be protected and by whom
02:43:17 protected and by whom secondly how hoses might be deployed at which selected levels at which times and with
02:43:22 with what and with what objective in 20 questions on rice it is it is estimated that it would take 20 to 40 minutes to evacuate 350 people
02:43:33 20 to 40 minutes to evacuate 350 people from a 20-story building in tenable conditions with residents being of average age and fitness with evacuees in single file on the stairway
02:43:42 stairway thus
02:43:43 thus whilst it might have been theoretically possible and therefore it can be said that attempts should have been made to carry out a full evacuation the right evacuation model would be compromised due to
02:43:58 the absence of any effective means of communicating to residents any evacuation plan fire comp augmentation had been subject to multiple failures conditions throughout sections of the
02:44:09 conditions throughout sections of the stairway were not tenable the integrity of the stairway had not and could not be maintained while some occupants were of average asian fitness there was no available information with regards to numbers who
02:44:20 information with regards to numbers who were not fit and whose disabilities might impact on an orderly evacuation in single file so as to the viability of self-evacuation and search and rescue
02:44:33 self-evacuation and search and rescue we adopt and repeat what we set out in paragraphs 98 to 109 of our closing submissions for phase one however we also make the following points please the whole purpose of modern construction
02:44:46 the whole purpose of modern construction of high-rise residential buildings is complementation and evacuation is therefore never really for consideration grenfell tower as originally built did provide complementation
02:44:57 provide complementation the effect of the refurbishment work would be to fatally undermine this building design components but this was not appreciated at the time of the fire stay put was not lfp policy but a
02:45:08 stay put was not lfp policy but a nationally accepted design concept nationally massive actual evacuation was not routinely considered nor was any training given on the evidence as was made clear by professor torreira in his
02:45:21 made clear by professor torreira in his evidence
02:45:22 evidence training on full evacuation was not undertaken partly because occasions were full evacuation were required were so rare
02:45:30 rare in the case of the lfb and following la canal in consequence of the coroner's findings no the plan publicity campaign was to stay put as a general observation staple was
02:45:42 as a general observation staple was never intended to be universally applicable the advice is if we're not affected by smoke or flames stay put if you are so affected and can get out do so
02:45:54 get out do so but what training was given and to what purpose no or no adequate training was provided to the officers and firefighters
02:46:05 to the officers and firefighters by the lfb because evacuation was so rarely needed rice was not known it's not well known prior to grenfell and there is no evidence that any
02:46:16 and there is no evidence that any evacuation technic training is undertaken by any fire and rescue service nearly five years after the fire there has been evacuation training after the fire but it deals with situation in
02:46:27 the fire but it deals with situation in which evacuation should be considered not how evacuation is to be achieved this is in our respectful solutions so critical
02:46:34 critical it is one thing to say it should be considered however this wholly ignores the practical reality of whether it is viable and feasible if so
02:46:42 if so how
02:46:43 how is it to be achieved in a building such as grenfell tower that did not commit it by reason obvious construction and limitations
02:46:55 in terms of restriction restrictions on evacuation on the night we submit there's a distinction between mass or building wide evacuation and the evacuation of individuals respectively
02:47:07 respectively we submit it's not correct to assert that everyone instructed to evacuate would have succeeded in doing so themselves and would thereby have survived
02:47:18 survived as to national guidance and the absence of it if consideration of evacuation is so important which with new building materials and methods it is
02:47:29 new building materials and methods it is one must ask why is there no training on how to evacuate a building such as grenfell tower almost five years after the fire
02:47:36 the fire throughout the inquiry experts inquiry experts have acknowledged the difficulties in evacuation for example mr mcguck noted no tannoy or system to communicate with residents the
02:47:47 system to communicate with residents the rapidity of fire spread the failure of compartmentation the stairwell becoming increasingly increasingly compromised and the difficulties posed in evacuating residents with mobility issues
02:47:58 residents with mobility issues no expert has given evidence to how these difficulties of communication and smoke etc could be overcome this simply has been no evidence as to method
02:48:06 method simply the criticism that somehow lfb should have tried
02:48:13 if there was no means of communication if the stairwells were smoke logged the only people who could be evacuated were those who could be reached and escorted by firefighters this is what officers welsh
02:48:25 this is what officers welsh goldborn
02:48:26 goldborn and all other firefighters set out to do the formal declaration of abandonment have stayed put was relevant to the control room they being the only people in remote communication with those trapped in the tower on the five round
02:48:38 trapped in the tower on the five round evacuation was being put into practice when possible the essential problem is this respectfully building designs of the 1960s and 1970s specifically took account of the
02:48:49 specifically took account of the potential need to evacuate they did so by eliminating that necessity in the by designing in the principle of compartmentation once that design is tampered with by
02:49:00 once that design is tampered with by alteration and refurbishment compartmentation may no longer exist at grenfell tower it was not a case of pump augmentation failing it had been removed by the design of the refurbishment
02:49:12 by the design of the refurbishment the reason why no one can say how evacuation could have been viably achieved at grenfell or in an analogous situation is that the core design made evacuation unnecessary and impossible in a single
02:49:24 unnecessary and impossible in a single staircase building the only remedy would have been to have reverted to the initial design model so so in conclusion we respectfully submit as follows
02:49:36 submit as follows mr welsh was reasonably entitled to assume that grenfell tower had in its refurbished state been designed and built safely and in accordance with the building regulations therefore he was entitled to assume that
02:49:48 therefore he was entitled to assume that the building design concept of stay put remained valid tragically this reasonable assumption was not valid because of the gross failures of those involved in the design construction and approval of the
02:49:59 construction and approval of the refurbishment fault for this tragedy and the enormous loss of life rests squarely with them they cannot evade the responsibility by seeking to blame the actions of firefighters including senior staff on
02:50:11 firefighters including senior staff on the night
02:50:12 the night to permit them to do so would compound their egregious failures mr welsh had received no training which would have equipped him to appreciate how and why the fire at the tower was
02:50:23 how and why the fire at the tower was baby as it was and other than doing what he did what other actions might be taken in consequence even before the abandonment to stay put the actions he took on the night were prompted by a desire to achieve the
02:50:34 prompted by a desire to achieve the rescue and safe evacuation of as many occupants of the tower as possible if it is still asserted a viable evacuation of residents was possible then in this task he and his colleagues
02:50:46 then in this task he and his colleagues were hampered by the complete lack of a any training as to how this might be achieved
02:50:51 achieved b the absence then and now of any practical guidance as to how this might be implemented uh respectfully we maintain the position that for the reasons set out in our closing submissions for phase one
02:51:03 closing submissions for phase one paragraphs 98 to 109 a total evacuation self or assisted was never viable at grenfell tower within the short window of opportunity that existed
02:51:14 existed it is one matter to say a fuller evacuation should have been considered before the abandonment of state but however it is in order to get altogether different matter to say that such is viable
02:51:25 viable this all the more so when no single expert from whom the inquiry has heard has suggested how this could have been achieved with a greater saving of life in those circumstances mr chairman we very respectfully
02:51:37 very respectfully invite you to reconsider the fatal findings in this regard to see the extent to which if at all
02:51:44 all they remain findings that you consider properly to be made
02:51:51 be made thank you sir well thank you very much mr brown
02:51:56 the next statement is due to be made by miss stud on queen's council on behalf of the mayor of london but she's in the program for two o'clock and i think the sensible course now would therefore be
02:52:08 sensible course now would therefore be to adjourn until uh two o'clock so that we all have time for some lunch so thank you very much two o'clock please
02:52:28 you