Opening Statements (4 June 2018 - Pt 2 of 2)

Full transcript

00:00:21 thank you yes sir Thank You mr. chairman mr. chairman before I continue I should just say that I am about to go through the

00:00:33 say that I am about to go through the key points in the chronology of the night and there is a series of photographs of the building on fire during the course of my presentation

00:00:44 during the course of my presentation which now continues to follow I did get around some representatives of your participants during the lunch break but I fear not enough and so I'm going to have to repeat I'm afraid the the

00:00:56 have to repeat I'm afraid the the trigger warning now there are images which we are going to look at which some may find distressing they're not a video and there's no more sound but they are

00:01:07 and there's no more sound but they are still photographs of the building on fire

00:01:09 fire and so if anybody thinks they might feel it that these are distressing then I think now would be the time for them to leave yes well if anyone feels uncomfortable about seeing these

00:01:20 uncomfortable about seeing these photographs do feel free to get up and leave now I'm quite happy to wait a minute or two while you do say I don't see any sign of movement so I think mr. millet mr. Chanin thank you very much

00:01:33 millet mr. Chanin thank you very much mm-hmm in terms of the other key points in the chronology including the lfb response the lfb provided us very

00:01:45 response the lfb provided us very recently with a very detailed timeline report for the first hour after the first attendances of the pumps at Granville Tower which runs from that

00:01:56 Granville Tower which runs from that point until 2 a.m. also that timeline is in a document which was disclosed to core participants pretty well immediately last week it is a heavy heavily caveated

00:02:09 last week it is a heavy heavily caveated report and great caution should be taken with the times and the events in it saved where indicated and I should just make it clear but although it is we find an extremely helpful document it is not

00:02:22 an extremely helpful document it is not an inquiry document from our own work we can identify the following particularly important time points in the night with

00:02:33 important time points in the night with some degree of confidence

00:02:38 although of course the accuracy of these time points does depend on how the evidence emerges after the first attendance of the first four pumps at

00:02:51 attendance of the first four pumps at 1:13 the lfb and specifically firefighter Mike Dowden who was watch manager be from g27 one pump from North

00:03:02 manager be from g27 one pump from North Kensington made the first request for a hydraulic platform and make pumps six in other words increase the attendance

00:03:13 in other words increase the attendance of fire engines attending the scene and as I've said before the reference to pumps is the number of Ferengi's at the scene or or requested make pumps six is

00:03:25 scene or or requested make pumps six is to increase the number of foreign Jews from four to six firefighter Dowden was the first incident commander at the scene but 114 a.m. the order for the

00:03:39 scene but 114 a.m. the order for the hydraulic platform was changed to a high reach ladder or aerial appliance there is some evidence to be explored in

00:03:50 is some evidence to be explored in detail that will also at 114 and so after pumps have been made up to six the first firefighter crew opened the

00:04:02 first firefighter crew opened the kitchen door of flat 16 for the first time by 1:15 a.m. a hose stream was being applied to the East elevation and

00:04:14 being applied to the East elevation and at this point burning debris was continuing to fall down the fire by now having spread to level 5 floor five but

00:04:26 having spread to level 5 floor five but 119 the LF be called for make pumps 8 increasing requested attendants from 6 to 8 there is some evidence to be

00:04:41 to 8 there is some evidence to be explored in detail that the first firefighter crew actually got into the flat 16 kitchen at about 1:20 a.m. after pumps have been made up to eight

00:04:54 after pumps have been made up to eight and attempted to extinguish the fire within the kitchen but 1:24 a.m. the LF be called to make pumps 10 by 1:26

00:05:09 be called to make pumps 10 by 1:26 a.m. the fire has spread vertically up the right-hand column on the east face a climb of some 19 stories about 50 meters

00:05:21 climb of some 19 stories about 50 meters in the 12 minutes also since the fire took hold of the cladding at 114 at the latest

00:05:30 latest and according to dr. lanes preliminary report about 20 flats were exposed to the flame front by this point but 127

00:05:42 the flame front by this point but 127 a.m. the LF be called to make pumps 15 plus now to aerial appliances but what

00:05:53 plus now to aerial appliances but what by 1/9 129 the fire had reached the very top of the East facade and here is figure 90 from professor bisby's report

00:06:07 figure 90 from professor bisby's report which is an annotated extract as the slide says from the CCTV footage from the Southwest camera and correcting the time stamp it gives 129 and you can see

00:06:20 time stamp it gives 129 and you can see there the fire having reached the very top of the East elevation in the northeast corner of the building but around the same time 129 the LF be

00:06:34 around the same time 129 the LF be called to make pumps 20 and 4 to fire and rescue units or fr use but 131 the

00:06:45 and rescue units or fr use but 131 the LF be called to make pumps 25

00:06:50 at 1:36 a.m. the fire was spreading in two opposite directions laterally on the east elevation of the tower towards the

00:07:01 east elevation of the tower towards the northeast corner and towards the southeast corner and you can see from this slide now exhibited that there were

00:07:15 this slide now exhibited that there were multiple internal fires by this point in the northeast part of the building you will also see that the fire has spread southwards towards the southeast corner

00:07:31 southwards towards the southeast corner beyond the column marked b5 and that column is the column which abuts the kitchen to flat 16 but 140 station

00:07:44 kitchen to flat 16 but 140 station manager Andrew Walton from Kingston arrives to take command as incident commander at or at some point before

00:07:55 commander at or at some point before 1:50 a.m. station manager Walton took over from watch manager Mike Darden who had been incident commander from arrival

00:08:07 had been incident commander from arrival of the first pumps until that point we will be exploring as best we can what happened at hand over from incident

00:08:18 happened at hand over from incident commander Dowden to incident commander walton by 142 a.m. the fire had spread

00:08:29 walton by 142 a.m. the fire had spread to the North elevation via the top of the northeast corner column and here is a photograph taken at some distance from the north as is shown by the purple

00:08:42 the north as is shown by the purple arrow on the plan to the left of the photograph which shows where the fire was on the building at that time

00:08:52 by 152 the fire on the exterior of the North elevation was well developed not

00:09:04 North elevation was well developed not only was it spreading across the North facade but it was also spreading southwards across the East facade but this photograph has the purple arrow choses taken from the east and shows how

00:09:19 choses taken from the east and shows how the fire right up and down the North elevation had taken hold and also on the top few floors how the fire had moved from column B 5 in a southwards

00:09:31 from column B 5 in a southwards direction towards the south east column of the building above level 17 and by this time as you can see there were

00:09:43 this time as you can see there were multiple internal fires on the east face according to dr. lanes preliminary calculations some 26 fire flats were exposed to the flame front at this time

00:09:58 at 2:04 a.m. the LF be called to make pumps 40-plus for aerial appliances a 40

00:10:11 pumps 40-plus for aerial appliances a 40 pump fire is a very rare occurrence indeed Commissioner Danny cotton who has provided a witness statement to the inquiry will say that the last one was

00:10:25 inquiry will say that the last one was in 2012 and the one before that was in 1973 at 2:06 a.m. the LF be called a

00:10:37 1973 at 2:06 a.m. the LF be called a major incident which implemented gold silver and bronze command structure at 208 a.m. the fire was progressing as we

00:10:53 208 a.m. the fire was progressing as we can see from this picture diagonally across the top of the East face and diagonally across the North Face

00:11:04 diagonally across the North Face by 2:10 a.m. some 34 flats were exposed to the flame front by dr. lanes current provisional estimates at about 2:15 a.m.

00:11:21 DAC McLaughlin takes over as incident commander from mr. Walton and one minute later calls for 10:00 fr use fire rescue

00:11:36 later calls for 10:00 fr use fire rescue units we will be exploring the rolls and the precise order of command as between station manager Walton and DAC McLaughlin and group manager Welch in

00:11:49 McLaughlin and group manager Welch in the period between 152 to 15 by 2 22 the fire had passed around the southeast

00:12:00 fire had passed around the southeast corner column of the tower at its topmost paths and was now beginning to spread downwards across the south face by 2:23 a.m. some 53 flats were exposed

00:12:14 by 2:23 a.m. some 53 flats were exposed to the flame fronts by dr. lanes current provisional estimates by 2:30 a.m. the whole of the east face of the tower was

00:12:26 whole of the east face of the tower was reported to be fully involved in the fire at 2:32 a.m. the LF be called make aerials for but at 2:44 a.m. Assistant

00:12:41 aerials for but at 2:44 a.m. Assistant Commissioner ro took over from Deputy Assistant Commissioner McLaughlin as incident commander at 2:47 a.m.

00:12:53 incident commander at 2:47 a.m. Assistant Commissioner Roe took the decision to change the fire survival guidance formally from stay-put to

00:13:04 guidance formally from stay-put to advise people to make efforts to leave the building

00:13:09 based on a preliminary analysis of the CCTV cameras in the lobby of the tower by this time 2:47 a.m. it would appear that around

00:13:23 2:47 a.m. it would appear that around one hundred and eighty seven occupants for 64 percent had evacuated the tower leaving some 107 people still within the

00:13:34 leaving some 107 people still within the building after the stay-put guidance was formally changed the CCTV footage suggests that a further thirty six

00:13:47 suggests that a further thirty six additional occupants evacuated from Grenville tower by about 249 a.m. the

00:13:59 Grenville tower by about 249 a.m. the fire had started to attack the top of the West face at the northwest corner and then started spreading across and down that face by 308 a.m. the fire was

00:14:16 down that face by 308 a.m. the fire was spreading laterally across the West face as you can see from this picture and by 309 only a minute or so later some 70

00:14:29 309 only a minute or so later some 70 flats were exposed to the flame front or had been by 3:48 a.m. large parts of the

00:14:41 had been by 3:48 a.m. large parts of the south face were now alight this photograph is taken from the south east corner of the building as the purple arrow shows you can see there on the

00:14:54 arrow shows you can see there on the left the structure of the roof structure at Barrington walk and the fire on the south face in the diagonal pattern

00:15:08 by 403 am to the to flame fronts wrapping round the building had converged at level 23 of the southwest

00:15:21 converged at level 23 of the southwest top corner of the building by this time some 98 flats were exposed or had been exposed to the flame front

00:15:32 exposed to the flame front according to dr. lane at 4:43 multiple internal fires were arranging around the

00:15:43 internal fires were arranging around the building by that time some 106 flats had been exposed to the flame front but 447 what we believe to be the third last

00:15:59 447 what we believe to be the third last evacuees from the tower evacuated at 6:05 a.m. the second last evacuee

00:16:10 6:05 a.m. the second last evacuee evacuated at 8:07 a.m. the last occupant of the tower evacuated but 1302 on the

00:16:23 of the tower evacuated but 1302 on the 14th of June sistent commissioner Ellis took over as incident commander and at 19:55 p.m. on the 14th of June

00:16:36 19:55 p.m. on the 14th of June assistant commissioner Ellis declared that there was no longer any savable life in the building as part of the factual evidence that you will hear in

00:16:47 factual evidence that you will hear in phase 1 we will be trying to piece together a much more detailed chronology of the events on that night to that end

00:17:00 of the events on that night to that end the evidence of the bereaved the survivors and the residents will be crucial in helping us to understand the conditions in and around the tap the tower on that night and particularly the

00:17:14 tower on that night and particularly the conditions within individual flats in the lobbies and on the stairs which were so critical in terms of the individuals ability to escape and I now turn to themes which

00:17:33 escape and I now turn to themes which are emerging and key lines of inquiry for phase one in this final section of our opening I want to outline some of

00:17:45 our opening I want to outline some of the preliminary themes which are emerging both from the factual and the expert evidence and to outline some of the key lines of inquiry which will be

00:17:56 the key lines of inquiry which will be which we will be pursuing in this phase one of the inquiries work I should emphasize that what follows is not intended to be an exclusive list of

00:18:07 intended to be an exclusive list of topics that we will be covering the expert evidence that we have already served as all is already extremely voluminous and it would be impossible to

00:18:18 voluminous and it would be impossible to capture in my opening now all of the detailed issues which are likely to arise what I do want to do is to outline some of the most significant aspects of

00:18:29 some of the most significant aspects of the evidence to date and the key questions which will have to be examined during this part of the inquiries work

00:18:43 first of all calls and origin in terms of cause and origin of the fire as I have already outlined the available evidence currently suggests that the

00:18:55 evidence currently suggests that the origin of the fire was in or around the tall fridge/freezer in the kitchen a flat 16 the evidence also suggests that it is more likely than not that the fire had an accidental

00:19:08 than not that the fire had an accidental cause however vital expert work in this area is continuing and in particular in the field of forensic electrical

00:19:19 the field of forensic electrical engineering and as I've already indicated the inquiries preliminary forensic electrical engineering work started in November last year it is

00:19:30 started in November last year it is hoped that dr. Duncan gloves examination of the wiring in flat 16s kitchen and the electrical appliances within the kitchen will help to narrow down the area of origin and also to identify the

00:19:45 area of origin and also to identify the cause of the fire this type of forensic examination is inevitably painstaking and the inquiry will provide an update as to progress as soon as it can as I've

00:19:58 as to progress as soon as it can as I've already said it's hoped that a report from dr. Glover will be available during the course of phase 1 and in good time before october the inquiry has also

00:20:10 before october the inquiry has also taken steps to obtain further factual evidence from the occupants of flat 16 all three of the occupants of flat 16 have cooperated with the inquiry and

00:20:22 have cooperated with the inquiry and they have provided the inquiry with supplemental statements which address key areas over and above those that they provided to the police in the statements

00:20:33 provided to the police in the statements which have already been disclosed mr. Kirby D whose call you have already heard and who was the principal tenant of flat 16 has given eight statements to

00:20:46 of flat 16 has given eight statements to the police including one very recently which we are still preparing for disclosure two participants and only just last Friday evening he helpfully provided the

00:20:58 evening he helpfully provided the inquiry with a statement as well an inquiry statement and he will be called to give oral evidence if necessary and if he is fit to do so in September a

00:21:10 if he is fit to do so in September a point I made earlier this morning mr. Kirby D lived in flat 16 to some 25 years prior to the fire he raised the alarm on the night of the fire including

00:21:23 alarm on the night of the fire including making the first 999 call which you've just heard alerting the fire brigade to the fire he was the only occupant of flat 16 to see the

00:21:36 only occupant of flat 16 to see the conditions in the kitchen before leaving the flat and he took on his mobile phone a series of videos from outside the tire which we believed to be the earliest

00:21:47 which we believed to be the earliest images available including of the fire breaking out of the flat and taking hold of the facade the witness statements of the two other occupants Elsa after-work

00:22:00 the two other occupants Elsa after-work II and Alma's kin foo both those they did for the police and those that they have done for the inquiry will also be read into the record

00:22:11 read into the record they were also occupants of flat 16 on the night of the fire and they escaped it is also hoped that this further factual evidence and that of the

00:22:22 factual evidence and that of the firefighters who fought the initial fire within the compartment within flat 16 will further assist in terms of how the fire started and how it developed and was able to exit into the facade that is

00:22:39 was able to exit into the facade that is the next topic exit of the fire from flat 16 in terms of fire spread out of flat 16 the inquiries experts including dr. Lane and professor Bisbee have

00:22:50 dr. Lane and professor Bisbee have identified a number of different possible routes by which flames could have escaped from flat 16 and ignited the facade a present the available

00:23:02 the facade a present the available evidence suggests that the initial fire may have been relatively small and certainly not reached flashover in other words the temperature at which everything in the fire room combusts

00:23:16 everything in the fire room combusts before it spread out of flat 16 and into the cladding at this stage of our investigations it appears that the most likely route of fire spread out of flat

00:23:28 likely route of fire spread out of flat 16 was via parts of the window surrounds which were penetrated by fire and combustible materials igniting within those surrounds before impinging upon

00:23:40 those surrounds before impinging upon exposed polyethylene edges of the ACP rain screen panels on the exterior professor torero has also addressed this

00:23:52 professor torero has also addressed this in detail in his report by using first principle the fit of first principles of physics his view is that a fire with characteristics common to any

00:24:03 characteristics common to any residential fire in the kitchen would have resulted in the loss of strength of the uPVC surrounding the window exposing the combustible components in the window

00:24:15 the combustible components in the window and leading to ignition of those combustible components of the facade system however this will be the subject of further investigation including by

00:24:28 of further investigation including by the inquiries experts who wish to investigate the rolls which may have been played by the various of the materials that were present in the window framing and the cladding system and to conduct further tests

00:24:45 external flame spread as to external flames spread more generally across the building the inquiries experts have identified a range of mechanisms which

00:24:57 identified a range of mechanisms which may have effect may have affected the fire spread on the night in Section 10 of dr. lanes report she has provided a detailed explanation of the materials

00:25:09 detailed explanation of the materials which were present both around the windows and in the facade system she has explained for example the extent to which the new windows and the rain screen system created cavities and voids

00:25:22 screen system created cavities and voids which were potentially significant in terms of the building's ability to resist the spread of fire she has identified six different

00:25:33 she has identified six different possible pathways pathways A to F but she has labeled them for fire spread both around the windows and also through the building envelope in Section six of

00:25:47 the building envelope in Section six of Professor Bisbee's report he attempts to explain which features of the building are likely to have affected vertical downward and horizontal flame spread all

00:25:59 downward and horizontal flame spread all of which appear to have played a significant part in the fire although he is clear that the that the presence of ACP rainscreen cladding with a highly

00:26:11 ACP rainscreen cladding with a highly combustible polyethylene core was the primary reason for the upward downward and lateral flame spread he has actively considered other factors including the

00:26:23 considered other factors including the role of the channels and cavities in the facade system and its geometry professor torero has also considered this topic

00:26:34 torero has also considered this topic although he has concluded that the physical details in this particular cladding system may have had an impact on flame spread rates upward flame spread rates were not particularly fast

00:26:46 spread rates were not particularly fast in comparison with inter national experience of trading fires and that detailing of the facade as opposed to its material composition may have had only a minor impact in terms of the evolution of this fire those

00:27:01 evolution of this fire those investigations are very much ongoing and they will be the subject or further expert investigation there are two

00:27:12 expert investigation there are two particular areas which require further consideration and they are first the extent to which the architectural crown at the top of the building may have

00:27:25 at the top of the building may have played a significant role in terms of lateral fire spread around the building both professor Bisbee and professor torero consider that the crown detailing

00:27:38 torero consider that the crown detailing on the building may have been responsible for the lateral fire spread on the building where the rate of lateral fire spread appears to have been it's at its fastest this lateral fire

00:27:51 it's at its fastest this lateral fire spread appears to result in a significant amount of burning debris falling down the building igniting the facade system in lower floors of the building the second area which will

00:28:04 building the second area which will require further investigation in particular is the extent to which the combustible PIR insulation both in the facade itself and around the windows may

00:28:15 facade itself and around the windows may also have played a role in terms of the flame spread on the night in terms of this latter point professor torero has sought to explain some of the complexities that were a feature of this

00:28:27 complexities that were a feature of this particular cladding system one of the features of his report is an explanation of the complicated relationship between the acp rain screen and the PIR

00:28:39 the acp rain screen and the PIR insulation his view is that is that the two interact and that the combination of the two is important to understand in terms of flame spread rates he also

00:28:52 terms of flame spread rates he also addresses the potential for the PIR insulation to burn for a longer time period which can be critical when defining the capacity of the fire to break back into the building

00:29:06 what is abundantly clear is that the building envelope created an intolerable fire hazard there was a catastrophic

00:29:17 fire hazard there was a catastrophic failure of the rainscreen cladding in terms of its ability to resist the fire spread across the walls of the building all of the relevant experts are clear

00:29:30 all of the relevant experts are clear that the consequence was a fire which affected multiple stories and multiple compartments with many post flashover fires occurring internally on multiple

00:29:42 fires occurring internally on multiple compartments and on multiple stories I turn next to the performance of the of the active and passive fire safety

00:29:54 the active and passive fire safety systems as to these it is important to recognize that the building was designed and maintained in the expectation that

00:30:05 and maintained in the expectation that nothing other than a single compartment fire would occur and that it could be dealt with by early fire service intervention the assumptions underlying

00:30:17 intervention the assumptions underlying this design intent and the regulatory framework underpinning those assumptions will be explored in more detail as part of the expert evidence and also at phase

00:30:29 of the expert evidence and also at phase two the key point for present purposes is that the active and passive fire safety systems were required to mitigate

00:30:41 safety systems were required to mitigate an extraordinary and unexpected event once compartment ation failed and a whole building fire was inevitable dr.

00:30:53 whole building fire was inevitable dr. Lane has made an assessment of how those active and passive fire safety systems performed on the night of the fire her investigation has so far highlighted a

00:31:04 investigation has so far highlighted a number of areas of serious concern

00:31:09 those include include the following flat front doors the performance of the flat front doors in terms of that one their

00:31:21 front doors in terms of that one their composition and to their ability to resist the spread of fire and also three their condition and maintenance is a matter for investigation one particular

00:31:33 matter for investigation one particular question we will need to explore is whether these self-closing devices were properly installed and maintained that is relevant to the question of the smoke conditions in the lobbies and in the

00:31:47 conditions in the lobbies and in the single staircase on the night professor torero has also addressed this topic in his report he has explained that although a fire of considerable severity

00:31:59 although a fire of considerable severity was progressing across the exterior of the building he considers it reasonable to have expected the internal compartment ation to have performed on the night because the flats ought to

00:32:12 the night because the flats ought to have been capable of withstanding the internal fires in the flats and not leading to a compromise of the lobbies and the stairs it will therefore be

00:32:23 and the stairs it will therefore be necessary to explore in some detail how the flat front doors performed on the night secondly the firefighting lift failure of the lift to perform as

00:32:37 failure of the lift to perform as appears to have been intended as a firefighting lift is a matter of very serious concern there are a number of indications which suggest that the lift did not have the firefighting features

00:32:49 did not have the firefighting features it was intended to and did not operate when the lfb expected it to on the night that will be the subject of further investigation including understanding

00:33:01 investigation including understanding how the lift could have affected firefighting and rescue operations on the night and also obtaining from the relevant early attendance firefighters

00:33:12 relevant early attendance firefighters what they found when they tried to get the lift to work

00:33:19 the next issue furnish you is the water supply or pressure question and in detail the question of whether a wet

00:33:31 detail the question of whether a wet rise a fire main would have all should have been provided instead of a dry riser there is some evidence to suggest that there were difficulties associated with accessing the dry risers and

00:33:42 with accessing the dry risers and gaining access to water particularly on higher levels within the tower although a wet riser might have suffered from similar difficulties in terms of coping

00:33:54 similar difficulties in terms of coping with multiple hoses within the tower it will be necessary to explore further whether the a wet rising main could have enhanced the speed of response to the

00:34:05 enhanced the speed of response to the initial fire and the ability to maintain water pressure higher up the tower more generally as to water pressure available at Grenville tower on the night the

00:34:18 at Grenville tower on the night the inquiry has instructed a water expert to advise on water supply systems and issues at the tower he is dr. Ivan Stoyanov who is senior lecturer in water

00:34:31 Stoyanov who is senior lecturer in water systems engineering at Imperial College in London and he will be preparing a report on that subject effect for phase 2 of the inquiries work

00:34:44 finally we have smoke ventilation as an issue there are questions over the smoke ventilation system and whether it

00:34:55 ventilation system and whether it operated as intended there is also some evidence to suggest that the system didn't operate as it should have on the night and that the fire service attempted to take control of the system

00:35:06 attempted to take control of the system but who are unable to do so whilst it is very important to recognize the limitations of this system even when it's is operational including the fact

00:35:17 it's is operational including the fact that this system was never designed never designed to address smoke control on multiple lobbies as opposed to a single floor and couldn't be expected to provide complete protection to the

00:35:30 provide complete protection to the single staircase during the fire nonetheless it'll be necessary to explore what the firefighters found on arrival at the scene on the night it will also be necessary to examine how

00:35:42 will also be necessary to examine how and the extent to which the system might have been capable of operating to support the fire and rescue efforts or to impede will diminish the spread of speck on the night my next turn two

00:36:00 speck on the night my next turn two additional lines of inquiry in addition to the lines of inquiry report I have already identified dr. lanes report also highlights some other issues with the

00:36:11 highlights some other issues with the safe fire safety systems in the building which will require further investigation the first is the fire doors to the single staircase the performance of the

00:36:23 single staircase the performance of the fire doors connecting the lift lobbies to the single staircase will have to be examined in detail this will include the extent to which these doors were able to resist the spread of fire and the extent

00:36:35 resist the spread of fire and the extent to which stair doors may have been held open during firefighting all search and rescue operations including by the presence of firefighting hoses or because of a failure in any self closing

00:36:48 because of a failure in any self closing or other closing devices the second issue

00:36:55 issue for any further inquiry is the performance of the single staircase itself and the extent to which it complied with the relevant regulations that will include examination of its

00:37:08 that will include examination of its width and the provision for handrails and whether it impeded the passage of firefighters during operations especially when wearing breathing apparatus or extended duration breathing

00:37:21 apparatus or extended duration breathing apparatus thirdly the gas supplies and installations to the tower this includes the extent to which the gas suppliers

00:37:33 the extent to which the gas suppliers were capable of being isolated on the night and the compliance of the gas installation works that had been carried out inside the tower a specialist gas

00:37:44 out inside the tower a specialist gas expert mr. Rodney Hank Hawkes who is director of gas distribution Solutions Limited has been instructed by the inquiry to consider these issues and he

00:37:55 inquiry to consider these issues and he will be preparing a report at Phase two in terms of our phase 1 fact-finding we will want to understand what happened in terms of isolating the gas supply on the

00:38:06 terms of isolating the gas supply on the night and what evidence there is of any compromise of or breaches to the gas piping inside the building during the fire

00:38:24 our next turn two conditions inside the building and the movement of individuals

00:38:35 certain patterns are emerging about the conditions inside the building and the movement of persons within it on the night we already have important

00:38:48 night we already have important information about the place where each of the deceased was found and also about the pattern of evacuations which we have been able to piece together from the

00:39:00 been able to piece together from the CCTV footage in the lobby of the tower there is also some CCTV footage from inside the tower in the lift and on the seventh floor Lobby and the pattern of

00:39:12 seventh floor Lobby and the pattern of damage to the building also tells us something about the conditions which occurred in different parts of the building on the night dr. Lane has addressed this in some detail in section

00:39:24 addressed this in some detail in section 20 of her report and professor torero has done the same in his report at sections five point three point two to five point three point three of his report but there are some themes already

00:39:38 report but there are some themes already evident from the information currently available to the inquiry first it appears that below level 18 the majority of the deceased were found in the floor

00:39:51 of the deceased were found in the floor where they resided above level 18 the majority of the deceased have moved upwards and many up to level 23 secondly

00:40:03 upwards and many up to level 23 secondly on every level of the tower people escaped away from the sixth flat on each floor ie the flats which straddled the north and east phases of the building

00:40:14 north and east phases of the building and which were directly above flat 16 no fatalities were recovered from the sixth flat on any floor in other words the

00:40:25 flat on any floor in other words the flats in the northeast corner of the tower

00:40:29 thirdly given the movement of persons inside the building and based on the damage patterns to the inside of the building it appears likely that the

00:40:41 building it appears likely that the lobbies and stare at certain levels and times may have become particularly affected by heat and smoke possibly involving a hot zone in the middle of

00:40:53 involving a hot zone in the middle of the tower between levels 13 and 16 fourthly we will want to explore as precisely as we can how the conditions

00:41:04 precisely as we can how the conditions in the lobbies and on the stair changed as the night progressed some of the firefighter evidence suggests that the lobbies and the stair between level 6

00:41:15 lobbies and the stair between level 6 and 10 began to be particularly compromised with smoke at around 1:30 8 a.m. fifthly the available CCTV evidence from the

00:41:29 the available CCTV evidence from the lift and the 7th floor lobby also supports the contention that between 1:30 a.m. and 1:40 a.m. the conditions in the lower part of the tower began to

00:41:41 in the lower part of the tower began to deteriorate markedly sixthly between 159 a.m. and 258 a.m. in particular about level 10 some of the

00:41:55 particular about level 10 some of the firefighter witnesses have described as incredibly hot quotes unquote and the stair at level 10 is also described as quotes boiling-hot quote some quotes

00:42:08 quotes boiling-hot quote some quotes with thick heavy smoke between level 7 and 12 7th a preliminary analysis of a number of the 999 calls which has been

00:42:20 number of the 999 calls which has been done by Professor torero suggests that early smoke migration between the 11th and the 14th floors may have occurred

00:42:33 viii this is a slide or pictures from Professor Toreros report he has identified some police helicopter

00:42:44 identified some police helicopter footage which shows that there may have been early passage of smoke through the building at about 2:00 a.m. with smoke coming from windows on the south and

00:42:57 coming from windows on the south and west facades on the opposite side of the building to where the fire was spreading on its east face indicating that internal compartment ation had been

00:43:09 internal compartment ation had been breached at both mid-level in the building and around floor 20 what you see on the screen there are figures 49 50 and 51 the professor Toreros Report

00:43:23 50 and 51 the professor Toreros Report as you can see smoke emanating in all three pictures from a room on that floor about 420

00:43:37 we will want to explore all of these topics in more detail as the elbe evidence develops and try to understand precisely how the conditions in the building developed on the night and how

00:43:49 building developed on the night and how that affected the ability of people to evacuate if they made attempts to do so we will also be exploring whether any failure of compartment ation inside the

00:44:02 failure of compartment ation inside the building was due to the physical features of the building including its doors and their closers or also to human actions on the night including the actions of the firefighters the next

00:44:16 actions of the firefighters the next topic will be top toxic gases professor purser who has been engaged as an inquiry expert we'll also be providing expert evidence on toxicity issues

00:44:28 expert evidence on toxicity issues including the extent to which toxic gases inside the tower are likely to have affected individuals behavior and led in some cases to their deaths he

00:44:40 led in some cases to their deaths he will also be providing evidence on the production of toxic gases of some of the materials which have been found within the tower including the cladding

00:44:51 the tower including the cladding materials and the materials which have been found around the refurbished windows his report will be provided as soon as it is available the last topic

00:45:05 soon as it is available the last topic for further investigation under this heading is helicopters the inquiry has been made aware of an ongoing IO PC investigation into the use of police

00:45:17 investigation into the use of police helicopters on the night of the fire including whether that might have encouraged some residents to remain in place or to move to the top of the tower

00:45:29 place or to move to the top of the tower and whether the operation of the police helicopters could have worsened the fire we anticipate hearing some factual evidence which may touch upon these issues and we will obviously make sure

00:45:40 issues and we will obviously make sure that the inquiry is apprised of the progress of the IO PC investigation as it develops

00:45:56 I now turn to the emergency services response and I start with basic issues from her perspective of a fire safety

00:46:08 from her perspective of a fire safety expert dr. Lane has also looked at a number of topics which are relevant to the building's responsiveness to firefighting on the night it is right to

00:46:20 firefighting on the night it is right to emphasize right at the star that dr. Lane is not a firefighter and has never been a firefighter and we'll leave qualitative questions about the firefighting response to mr. Steve

00:46:32 firefighting response to mr. Steve McGurk in phase 2 he is the inquiries firefighter expert but an assessment of fire safety matters within Grenfell

00:46:43 fire safety matters within Grenfell tower and as to how it behaved on the night necessarily requires consideration of the fire services response to the incident dr. Lane has highlighted two

00:46:55 incident dr. Lane has highlighted two particular points first the ability of the fire service to carry out external firefighting again the fundamental assumption under the relevant regulatory

00:47:08 assumption under the relevant regulatory regime is that all firefighting will be carried out internally hence a rising main is provided for that purpose inside the building in this case a dry riser

00:47:21 the building in this case a dry riser but even though there was no requirement to make provision for external firefighting access she has explored and will continue to explore the extent to

00:47:32 will continue to explore the extent to which effective external firefighting operations were possible and any factors which hampered those external firefighting efforts on the night second

00:47:44 firefighting efforts on the night second the extent to which the fire service itself were able to communicate with individuals within grenfell tower on the night and in particular the means

00:47:55 night and in particular the means available to the fire service for doing what they what for doing that once the stay-put policy was formally abandoned at 2:47 it will be necessary to

00:48:07 at 2:47 it will be necessary to explore what methods of communication were used what they were and whether any of them were adopted on the night and if so with what effect in terms of the

00:48:21 so with what effect in terms of the evidence about the lfb response on the night as matters stand as of Friday we have disclosed to court participants 250 witness statements from lfp firefighters

00:48:34 witness statements from lfp firefighters out of a total of 615 disclosed to us by the police there are a further 11 lfp firefighter statements currently with the met awaiting non objection to

00:48:46 the met awaiting non objection to disclosure to the cps these statements were almost all taken by the met and they include statements not just from firefighters but from the investigation teams counselors and a

00:48:59 investigation teams counselors and a number of exhibits only statements of the statements that the inquiry has now disclosed to CPS as matters stand today we plan to read some 74 into the inquiry

00:49:12 we plan to read some 74 into the inquiry record say that they are publicly available but not to call the makers as all witnesses and we plan to call as oral witnesses some 52 firefighters to

00:49:25 oral witnesses some 52 firefighters to speak to their statements and to give further evidence orally and answer questions but we will keep these numbers under review the firefighter statements

00:49:36 under review the firefighter statements taken by the police are a vivid and valuable record of the collective and the individual firefighter experiences on the night commissioner Danny cotton

00:49:50 on the night commissioner Danny cotton who was the Commissioner of the London Fire Brigade and a firefighter from the age of 18 was present on the scene from 229 a

00:50:00 229 a that night she has described the fire in her detailed statement to the inquiry you will be hearing her evidence later in this phase one that she explains and

00:50:13 in this phase one that she explains and I quote I have never seen a building where the whole of it was on fire nobody has ever seen that it was incredible it was so alien to anything I had ever seen

00:50:26 was so alien to anything I had ever seen close quote that was the stated experience of all of the firefighters who attended the fire on the night whose evidence he will hear or read in the weeks to come

00:50:40 or read in the weeks to come nobody doubts that the fire itself in terms of scale and spread was unprecedented and exceptional in the

00:50:51 unprecedented and exceptional in the collective knowledge and experience of the London Fire Brigade and nationally whether such a building envelope fire was foreseeable in terms of type in

00:51:04 was foreseeable in terms of type in light of a growing body of evidence about previous cladding fires and what contingency plans might have been made for it by the lfb of different questions to which I will return shortly there are

00:51:22 to which I will return shortly there are we say eight questions about the lfb decision-making we are going to be exploring not only what the firefighters

00:51:35 exploring not only what the firefighters did on the night but what decisions they made those decisions were made by incident commanders we want to examine

00:51:46 incident commanders we want to examine when they were made and what the basis for those decisions was in policy and in training and whether any alternative strategies presented themselves and if

00:51:58 strategies presented themselves and if not why not we intend to examine their evidence rigorously then there are as I say eight basic questions which we will need to

00:52:10 basic questions which we will need to explore

00:52:12 explore those who took decisions the incident commanders in particular one what was the lfb policy if any Forex assessing

00:52:25 the lfb policy if any Forex assessing the materials and construction of a high-rise residential block - was that policy applied at Grenville tower 3 what

00:52:38 policy applied at Grenville tower 3 what if any was the policy in case compartment ation in a high-rise block failed 4 when exactly did it become

00:52:49 failed 4 when exactly did it become obvious to the incident commanders on the ground at Grenfell tower that that compartment ation had failed 5 what if

00:53:02 compartment ation had failed 5 what if any change to their strategy did they put in place there after and how 6 why was the formal stay put policy

00:53:14 was the formal stay put policy maintained until 247 a.m. and not revoked earlier 7 what difference that revocation made given the volumes of

00:53:27 revocation made given the volumes of evacuation before that time and 8 how did the change in formal strategy get communicated to residents now this of

00:53:40 communicated to residents now this of course is not an exhaustive list of questions there are many more in terms of the evidence from the firefighters

00:53:51 of the evidence from the firefighters relevant to phase 1 those can be distilled into some 18 separate subtopics the response to the initial

00:54:02 subtopics the response to the initial fire in the kitchen of flat 16 incident command and control communications including a communications within the

00:54:13 including a communications within the building and B communications between incident command and those responsible for directing and carrying out of the firefighting response control

00:54:25 of the firefighting response control room its functions and responsibilities and in particular communication of fire survival guidance or FSG from the

00:54:36 survival guidance or FSG from the control room to occupants of Granville tower FSG and the stay-put policy including firefighters understanding of

00:54:48 including firefighters understanding of that policy its application and its withdrawal the quality of the mobile data terminal information for MDT information predetermined attendance or

00:55:06 information predetermined attendance or PDA information and policy

00:55:14 access to the fire ground and access to and from the tower including the effect of falling debris the establishment and

00:55:25 of falling debris the establishment and operation of the bridgehead during the course of the firefighting response fire spread smoke spread firefighting itself

00:55:39 spread smoke spread firefighting itself including the use of ladders aerial platforms etc the use and operation of breathing apparatus search and rescue

00:55:51 breathing apparatus search and rescue experiences dry risers including their use and functionality many water pressure related issues including any

00:56:03 pressure related issues including any previous difficulties encounter encountered fighting fires in high-rise buildings for example Trellick tower in April 2017 training the behavior of the

00:56:19 April 2017 training the behavior of the building during the course of evacuation all of those topics either separately and together will be examined in detail during phase one

00:56:36 I now turn to fire survival guidance and stay put advice in terms of fire survival guidance that was given to residence of Grenville tower on the

00:56:48 residence of Grenville tower on the night of the fire I want to say it just a little bit more at this stage it will be necessary to establish precisely what guidance residents were given both

00:56:59 guidance residents were given both before and during the fire and how that was understood and how it was acted upon we have evidence of fire action notices being provided in the tower as is

00:57:11 being provided in the tower as is illustrated from this photograph taken from dr. lanes report and the essence of the fire survival guidance for the stay-put policy is contained in the

00:57:23 stay-put policy is contained in the middle of that notice we will turn to the language of the notice in due course this particular notice was found in the

00:57:35 this particular notice was found in the lift lobbies by the lifts we want to understand how residents interpreted this sign and other guidance that they

00:57:48 this sign and other guidance that they were given and for those who left the tower in the early stages of the fire why they did so notwithstanding this advice I have mentioned earlier that the

00:58:01 advice I have mentioned earlier that the evidence currently suggests that around 187 occupants about 64% had evacuated the tower by the time the stay-put policy was formally abandoned at 2:47

00:58:15 policy was formally abandoned at 2:47 a.m. the evidence also suggests that the rate of evacuation substantially slowed from 138 a.m. before that time 144

00:58:30 from 138 a.m. before that time 144 people had left the building and after the stay-put guidance has changed an hour later at 247 or so only 36 people managed to escape the tower it may be

00:58:43 managed to escape the tower it may be that the withdrawal of the formal stay put guidance at that stage was just at a mere formality in light of the number of occupants who had managed to escape safely before that time on the

00:58:56 escape safely before that time on the other hand it may be that the formal maintenance of that advice until 247 am made all the difference between life and death for those who received fire

00:59:12 death for those who received fire survival guidance we will want to understand precisely what guidance was being given to them by lfb control or by others and what factors were influencing

00:59:24 others and what factors were influencing their decision whether to stay in their flats or to attempt to escape to that end a significant number of 999 call transcripts have been disclosed to core

00:59:37 transcripts have been disclosed to core participants and many may well be relevant to that question one pressing question is whether it was appropriate to maintain the formal stay put strategy

00:59:50 to maintain the formal stay put strategy whatever that was until 247 a.m. or whether it could and should have been withdrawn sooner in that regard evidence

01:00:02 withdrawn sooner in that regard evidence regarding the conditions in the lobbies and the stairs will be crucially important not least so as to understand at what times it would have been possible and safe for individuals to

01:00:13 possible and safe for individuals to escape if they had been advised to do so the submissions of the g3 group of bereaved survivors and residents assert

01:00:25 bereaved survivors and residents assert at paragraph 68 that it is beyond argument quote some quotes that many more would have survived than did survive if the stay-put policy had been

01:00:37 survive if the stay-put policy had been abandoned at 1:26 a.m. or at any rate long before 247 a.m. with respect that is not a proper submission first it is an assertion made

01:00:50 submission first it is an assertion made without any evidence and before any evidence is called secondly it is very far from beyond argument this is an inquiry to lay bare the truth

01:01:02 this is an inquiry to lay bare the truth it is not litigation and the question as to what effect that withdrawal of the formal staple policy and its timing actually had in fact what must be

01:01:14 actually had in fact what must be explored in the evidence before any conclusions can be reached about it as I have already mentioned we will be hearing from all of the incident

01:01:25 hearing from all of the incident commanders who were responsible for the decision-making on the 19 and we will seek to understand the factors which they took into account when making the

01:01:36 they took into account when making the decisions they did and the conditions the fire service was facing as the situation unfolded in front of them that will involve studying the lfb policies

01:01:49 will involve studying the lfb policies in place the national policies in place and whether the incident commanders were trained in those policies and whether that training informed their decision-making on the night the inquiry

01:02:03 decision-making on the night the inquiry will also consider the liaison between the firefighters and the other emergency services and the volunteers on the ground as well as the important question of the efficacy of the communications

01:02:15 of the efficacy of the communications between the lfb and the other emergency services as well as the communications themselves between individual firefighters on the ground on the night

01:02:29 mr. chairman finally before I conclude this opening statement I should like to provide if I may an update on the progress of preparation for Phase two in

01:02:43 progress of preparation for Phase two in order to provide a framework in which phase two can be managed the inquiry has updated its provisional list of issues a copy of this updated list can be found on the inquiries website two points

01:02:57 on the inquiries website two points should be noted by core participants first this is not and is not intended to be a final list of the issues that will be addressed by the inquiry inevitably

01:03:09 be addressed by the inquiry inevitably the list will be reviewed and revised raised as the inquiries investigation proceeds secondly and specifically the

01:03:20 proceeds secondly and specifically the inquiry team has been considering the final report published by Dame Judith Hackett on the 17th of May 2017 and her

01:03:31 Hackett on the 17th of May 2017 and her conclusions we will update the list of issues to reflect any further issues that need to be investigated which flow out of the Hackett report and in particular we will examine her

01:03:43 particular we will examine her recommendations some 25 also letters are about to be or have just been sent to the corporate and governmental core

01:03:55 the corporate and governmental core participants under Rule 9 of the inquiry rules 2006 those letters request written witness statements from persons from whom we propose to take evidence from

01:04:07 whom we propose to take evidence from those core participants and those statements have been asked to be served by 4:00 p.m. on the 28th of September 2018 the inquiry has asked that the

01:04:19 2018 the inquiry has asked that the statements address very specific identified issues by reference to the updated list of issues as well as any other matters in relation to which a

01:04:30 other matters in relation to which a witness may be able to assist the investigation where possible the inquiry has asked for witness statements from identified individuals who in the

01:04:42 identified individuals who in the inquiries view will be able to give detailed evidence in relation to relevant masses given the apparent need to extract a full and clear case out of

01:04:56 to extract a full and clear case out of many of these core participants rather than are relying on them to make admissions against their interests we expect these requests to be taken

01:05:07 expect these requests to be taken seriously and we will pursue proper detailed responses with vigor we hope that poor participants will resist the temptation to indulge in a

01:05:21 resist the temptation to indulge in a merry-go-round of buck-passing but we'll identify exactly their role in the chain of events leading to Grenfell tower becoming what our experts

01:05:33 tower becoming what our experts preliminary ly consider to be a major hazard it is hoped that those core participants who receive these invitations will not need to be reminded

01:05:45 invitations will not need to be reminded of the Chairman's powers of compulsion under section 21 of the inquiries Act the inquiry will provide phase 2 disclosure on a rolling basis between

01:05:57 disclosure on a rolling basis between October 2018 and the end of January 2019 it is anticipated that disclosure will be provided on an issue related basis

01:06:08 be provided on an issue related basis well though these precise dates will be confirmed in due course the Chairman I should say is minded to propose that in addition to any supplemental statements

01:06:19 addition to any supplemental statements that may be sought by the inquiry or provided by particular witnesses all core participants will provide by 30th of March 2019 a statement of response to

01:06:31 of March 2019 a statement of response to the issues this document which is to be verified by a statement of truth will contain an individual core participants response to the issues that directly concerned them as well as any other

01:06:43 concerned them as well as any other matters in relation to which they consider that they will be able to assist the inquiry the aim of the statement of response is essentially threefold first to enable the core

01:06:56 threefold first to enable the core participants to set out their precise positions in relation to the issues

01:07:02 secondly to provide an aid to the efficient case management of Phase two and thirdly to identify common ground as well as the truly contentious issues as

01:07:15 well as the truly contentious issues as matters stand the inquiry anticipates that phase two hearings will not start before April or May 2019 but as its investigation proceeds the

01:07:27 but as its investigation proceeds the inquiry will confirm a timetable and a start date for Phase two as well as further information regarding the structure of Phase two everything that I

01:07:39 structure of Phase two everything that I have said about the program for phase two will of course have to be subject to any decisions about it that any other panel members may make once they are appointed mr. chairman in conclusion

01:07:54 appointed mr. chairman in conclusion that reduced to its basic core elements is an introduction to and an overview of phase one of this inquiry I now propose to hand over to the first of the core

01:08:06 to hand over to the first of the core participants to address you but that will be tomorrow I'm glad to say we finished a little bit earlier than I was expecting to today I hope that causes no inconvenience to anybody I intend to reserve to myself a short

01:08:20 I intend to reserve to myself a short slot at the end of all the core participants all addresses in order to respond to any points that have arisen which may assist you all then further so

01:08:31 which may assist you all then further so mr. chairman subject to that that is what I propose to say by way of opening phase 1 to the inquiry in the timetable you would have noticed that I have been

01:08:42 you would have noticed that I have been asked to read Harley facades opening statement into the record I don't intend to lend my voice to the text but I will take it as read and it will be available

01:08:53 take it as read and it will be available from now on the inquiries website there's a gem unless I can assist you further the body else that is already a statement thank you very much indeed now I think we're going to hear next

01:09:05 now I think we're going to hear next from mr. Johnson on behalf of the Metropolitan Police mr. Johnson you weren't expecting to be on your feet this afternoon I think is that right and you might find it more convenient to start tomorrow morning yes

01:09:19 convenient to start tomorrow morning yes all right well we've gone rather shorter than we expected I don't suppose anyone will mind that too much so I will rise now and we'll resume tomorrow here at 10

01:09:31 now and we'll resume tomorrow here at 10 o'clock thank you very much

01:09:43 you