Phase 2 Overarching and Module 7 Closing Statements - Monday 7th November 2022 (1/2)

Full transcript

00:20:47 good morning everyone welcome to today's hearing well today we begin our last set of hearings during which we're going to hear a final closing statements from a

00:20:58 hear a final closing statements from a number of the core participants and we're going to start with uh Miss bar wise King's Council on behalf of the bereaved survivors and residents whom she represents and so she's there ready

00:21:13 she represents and so she's there ready no rush but we're ready to hear from you when you're ready

00:21:19 we end phase two very much as we began it in the sense that few Corps participants accept significant responsibility for what happened the

00:21:30 responsibility for what happened the department for leveling up and rbkc do acknowledge their significant errors but otherwise introspection is lacking apart from those who admit historic but

00:21:41 from those who admit historic but non-causitive mistakes self-interest is unhumbled by the disaster and indeed by this inquiry the light motif of grenfell is the

00:21:53 the light motif of grenfell is the failure of anyone to take responsibility either then or now other than Central and local government no Corp participant accepts any responsibility for the disaster each

00:22:06 responsibility for the disaster each instead seeking to diminish its own role each core participant continues to blame others and predictably now blames the regulatory regime for its permissiveness

00:22:17 regulatory regime for its permissiveness and tendency to be abused this is to overlook that the designers and contractors of grenfell all failed to address properly what the statutory requirements actually were and use a

00:22:30 requirements actually were and use a system including foam insulation patently in breach of the linear route which was the only route to compliance they could have been following

00:22:41 they could have been following whilst of course the building regulations were an outcomes-based regime at the time it was still necessary to demonstrate compliance with the functional requirements to the building control officer

00:22:53 building control officer each of the designers and contractors were untroubled both by what the regime required and whether they complied with it

00:23:01 it manufacturers were all too aware of both the functional requirements and ADB but sought to circumvent adb's linear route which prevented the use of their

00:23:12 which prevented the use of their products

00:23:13 products pausing there iconic well knew that its acmpe once made into cassette panels did not even conform to adb's diagram 40 because it was neither class 0 nor B

00:23:27 because it was neither class 0 nor B the entirety of the clotting system at grenfell did not conform to the linear route

00:23:33 route yet arconix BBA certificate applied to both riveted and cassette panels when we say little has changed since the beginning of phase two we mean that

00:23:44 beginning of phase two we mean that incredibly iconic remains in denial as to The lethality of its acmpe product Studio e although silent in this round of submissions when it last spoke

00:23:57 of submissions when it last spoke inaccurately sought to minimize its Central role as lead designer X over makes no mention of its own failures to produce an adequate fire safety strategy nor the fact that its

00:24:10 safety strategy nor the fact that its strategy was misleading both on the subject of the cladding and means of Escape for disabled people Harley who shamelessly drove the use of acm's PE product at grenfell for illicit

00:24:23 acm's PE product at grenfell for illicit profit which it shared with Ryden expresses dismay that manufacturers were able to take advantage of flaws in the regulatory system and insists industry

00:24:34 regulatory system and insists industry at large did not know acmp to be unsafe in fire

00:24:38 in fire this submission is brazen given highly well understood acmp was highly combustible one of its own designers contemporaneously said as we all know

00:24:50 contemporaneously said as we all know ACM will be gone rather quickly in the event of a fire bre argues that if regulations have been complied with intolerable fire spread

00:25:01 complied with intolerable fire spread would not have occurred that may be true if the bs-8414 route had been utilized but not if the linear route was followed but without due regard to the functional requirements

00:25:13 requirements bre also defends its desktop assessment criticized by Professor Bisby nhbc in misplaced Reliance on Professor bisby's desktop report seeks to justify

00:25:25 bisby's desktop report seeks to justify its irresponsible role in jointly producing technical guidance note 18 which introduced the concept of facade desktops as a route to compliance

00:25:37 desktops as a route to compliance we are acutely aware that the panel must examine all the circumstances of the disaster including both the immediate causes of fire spread and subsidiary causes which exacerbated the

00:25:49 causes which exacerbated the consequences of the fire such as lack of means of Escape for disabled people and the general management and maintenance of grenfell indeed we've encouraged and continued to

00:26:01 indeed we've encouraged and continued to encourage the panel to address even issues which were insufficiently causative such as poor workmanship during the refurbishment or not directly causative such as dishonest marketing by

00:26:13 causative such as dishonest marketing by the insulation managers manufacturers together with the bs-8414 testing regime and supervision of it by ucas it is clearly vital to explore the role

00:26:25 it is clearly vital to explore the role of insulation manufacturers despite their products not being responsible for the uncontrollability of the fire whilst we did not suggest Kings fans

00:26:36 whilst we did not suggest Kings fans k-15 product was causative at grenfell we had characterized King's band's Behavior as seminally causative and we remain of the view that they in celotex were seeking to misrepresent to the

00:26:48 were seeking to misrepresent to the market that foam insulations were universally safe for use at height to overcome the prohibition in the linear root of ADB as kingspan acknowledged in its 2015

00:27:00 as kingspan acknowledged in its 2015 reasons why campaign it was seeking to instill confidence in k-15 used in buildings with a habitable story 18 meters or more above ground and to

00:27:11 meters or more above ground and to prevent increasing specification of Rockwall and to spin such that the story is not to fire fire all the time it wanted to educate the market as to the

00:27:23 wanted to educate the market as to the insignificance of combustibility of individual products and the overall scheme of things even in the immediate aftermath of brenfell before it could have known whether its product had been causative

00:27:34 whether its product had been causative to any degree or not Kingsman sought to educate government by its political campaign to demonstrate materials of limited combustibility would fail King's Farm did this by a subsidiary

00:27:47 King's Farm did this by a subsidiary euroclad building weaknesses into King's fans tests of limited combustibility products

00:27:53 products this was not honest science it was seeking to manipulate the impact of the government's Building Safety tests King's fans should take little comfort from its k-15 product not being the

00:28:06 from its k-15 product not being the Catalyst for fire at grenfell becoming irreversible by comparison with a product whose core equates to diesel or lighter fluid the evidence should not be seen as

00:28:18 the evidence should not be seen as universally vindicating the use of foam insulations first according to Bisbee k-15 may have been relevant in initial escape from Flat 15 from Flat 16 due to its ease of

00:28:30 Flat 15 from Flat 16 due to its ease of ignition and k-15 unlike RS 5000 produced burning debris second Bisbee is clear that k-15 might be causative in other cladding configurations and these should be

00:28:42 configurations and these should be considered given the phase 2 experiments show k-15 is easily ignited and combustible one might question its use in both Timber framed buildings and buildings using

00:28:53 framed buildings and buildings using structurally insulated panels similarly as grenfell's cladding was not subjected to a bs-8414 test it might be argued and Bre does argue that it is not

00:29:05 argued and Bre does argue that it is not for the inquiry to consider such testing we disagree both the testing and certification process should be examined it became clear in module 2 that the

00:29:16 it became clear in module 2 that the whole certification regime by bodies such as BBA and the veneer of supervision of those bodies by ucas is in itself part of the problem despite that invitation to the panel to

00:29:29 despite that invitation to the panel to explore all such Avenues non-causitive in the legal sense we have nevertheless sought in our written submissions to identify the principal effective causes of the disaster so as to arrive at a

00:29:41 of the disaster so as to arrive at a minimalist roads Gallery by definition not definitive given the scale of the disaster and the number of those who died it is vital the

00:29:52 number of those who died it is vital the inquiry ascertains the principal effective causes so that those most accountable are identified and to prevent recurrence by targeted and robust recommendations this

00:30:04 targeted and robust recommendations this is the least that the bereaved and survivors can expect of us identifying the actual causes of the disaster is necessary for catharsis and to prevent distraction by false

00:30:16 to prevent distraction by false narratives which are dangerous in that they distort or conceal the steps necessary to prevent recurrence before attempting to allocate responsibility there are certain

00:30:28 responsibility there are certain implications of an out that comes based regime which were made clear in the module 7 evidence and which influence responsibility first as Professor torreiro told the panel the fire safety engineer Bears a

00:30:41 panel the fire safety engineer Bears a pivotal responsibility for safety in that it is their job to explain the functional requirements including those for B4 external fire spread within the fire safety strategy this includes

00:30:54 fire safety strategy this includes defining what adequately resist fire spread means and explaining what if any degree of fire spread in the external walls is acceptable this task is building specific and

00:31:08 this task is building specific and influenced by the evacuation strategy in the case of a high-rise building with a high with a stay put strategy no external flame spread can be tolerated thus the fire safety strategy is the

00:31:21 thus the fire safety strategy is the blueprint for a building's fire safety and demonstrates compliance with the functional requirements second it is incumbent on designers and contractors whether following the linear

00:31:33 contractors whether following the linear route or test route within ADB will achieve compliance with the functional requirements implicit in this is that neither roots to compliance with ADB nor the BBA

00:31:46 to compliance with ADB nor the BBA certificates demonstrating Conformity with tests can be slavishly adhered to without the designer applying their own judgment

00:31:55 judgment third whilst desktops in the sense of legitimate engineering assessments were always a means to compliance with the functional requirements the concept of facade desktops was introduced and

00:32:08 facade desktops was introduced and expressed to be a third route to compliance with ADB not by government but by bca's tgn drafted by industry whilst professors Torero and Bisby

00:32:20 whilst professors Torero and Bisby rightly stress the outcomes-based nature of the regime the reality of ADB was that it was intended to be and was wrongly as it transpired regarded as a

00:32:32 wrongly as it transpired regarded as a safe harbor namely a reasonably Safe Way of achieving compliance with the functional requirements whilst there were caveats within both the building regulations and ADB to the

00:32:44 the building regulations and ADB to the effect that the approved documents were not a guarantee of compliance nevertheless partly through ignorance and partly as it suited their purposes designers and contractors over focused

00:32:56 designers and contractors over focused on ADB as a safe route instead of considering the functional requirements two important issues on which the panel may wish to make findings are first that

00:33:07 may wish to make findings are first that the fire safeties engine the fire safety engineer's failure to define the functional requirements in the fire safety strategy was not legitimate and second that designers and contractors

00:33:19 second that designers and contractors Reliance on ADB without the exercise of judgment and Reliance on BBA certificates without interrogation was not legitimate the panel should bear in mind when

00:33:30 the panel should bear in mind when reflecting on whether to hold a phase three three on its proposed key recommendations as some suggest that there are several areas this is but one in which the panel will have to find

00:33:42 in which the panel will have to find groups of stakeholders in a given field acted in a way which is not logically supportable this Narrows yet further the field of those able to give reasonable unbiased

00:33:54 those able to give reasonable unbiased input to the inquiry there will be no shortage of tendentious arguments against sensible recommendations in our ranking of responsibility we split the protagonists into three groups

00:34:07 split the protagonists into three groups first those with responsibility for Speed Of Fire growth and spread namely those responsible for the use of acmpe second those with responsibility for contribution to spread of toxic smoke

00:34:18 contribution to spread of toxic smoke due to poor compartmentation third responsibility for failure to ensure adequate means of Escape for disabled people

00:34:27 people the need for concomitant peeps is addressed by others in our first group those responsible for the selection of acmpe we split the protagonists into two groups and rank

00:34:38 protagonists into two groups and rank them in order first iconic manufacturer of the ACM panel material second Studio e as lead designer and and

00:34:49 second Studio e as lead designer and and architect third ex-over as fire engineer those bearing secondary responsibility are Harley as cladding design subcontractor Ryden as design and build

00:35:00 subcontractor Ryden as design and build Contractor rbkc Building control and government as custodian of the statutory regime

00:35:08 regime iconic still insists its product in Rivet form achieving a Euro Class B despite subsequently achieving as low as an e in cassette form means its product was

00:35:21 cassette form means its product was theoretically safe iconic invites you to conclude there was nothing irregular about the test by which the B was achieved on the basis of Mr Burnham's statement that although the

00:35:33 Mr Burnham's statement that although the get the air gap may be an important parameter there is no unequivalent correlation between the air gap and performance iconic submission completely ignores Mr

00:35:44 iconic submission completely ignores Mr valor's contemporaneous email saying that the test in which a b was achieved for the riveted panel was arranged to pass and overlooks iconic's own evidence that the 50 millimeter Gap tested was UN

00:35:57 that the 50 millimeter Gap tested was UN representative of the Gap used in practice

00:36:01 practice more fundamentally iconic side steps the fact that its BBA certificate deliberately gave a wholly misleading impression as it related to both cassette and riveted panels

00:36:12 cassette and riveted panels iconic's argument that the material itself before fabrication into panels was capable of achieving a B therefore comes to nothing iconic argues it is wrong to equate its

00:36:25 iconic argues it is wrong to equate its product to petrol or other fuel given bisbian terraro's experiments so that without the cavity and insulation acmp would self-extinguish given most clouding systems comprise

00:36:37 given most clouding systems comprise both the cavity and insulation iconic's point is clearly bad it ignores the inquiry experts findings that the PE core is a highly volatile material

00:36:50 core is a highly volatile material once the aluminum skins delaminate PE core is a catalyst for an uncontrollable fire

00:36:58 fire Studio e as lead designer Bears the ultimate responsibility for the selection of acmpe the NBS specification it drafted predominantly in proprietary

00:37:09 it drafted predominantly in proprietary form was designed to ensure its Aesthetics were achieved without considering fire performance of the cladding panel Studio e never considered the functional

00:37:20 Studio e never considered the functional requirements for the external wall and the route to compliance was nowhere stated

00:37:27 stated Studio e should according to Mr Hyatt have reverted to X over to produce the B4 analysis of the chosen system the lack of thought by Studio e as to whether and how the selected rain screen

00:37:41 whether and how the selected rain screen met the functional requirements was evidenced by soon's failure to read Beyond page one of the BBA certificate he never attempted to ascertain acmp's performance in fire

00:37:53 performance in fire X over ought to have produced a fire strategy which explained how the functional requirements for the external wall were to be met by determining what if any fire spread was tolerable within

00:38:05 if any fire spread was tolerable within grenfell's facade instead exoda gave no guidance but created a false sense of security by saying the proposed changes which it knew involved cladding would

00:38:16 which it knew involved cladding would have no adverse effect this set a complacent tone for the fire safety from the outset in X over's subsequent an ad hoc involvement on the project it became

00:38:29 involvement on the project it became aware that combustible insulation was proposed yet at no stage did it intimate that it now needed to carry out an external wall analysis nor question what route to compliance was being followed

00:38:42 route to compliance was being followed given X over was repeatedly a top-tier fire engineer had it examined the chosen cladding system

00:38:50 system and advised Studio e that it was non-compliant it is likely Studio e would have changed the system given xova's primary business was fire testing and research of which the

00:39:02 testing and research of which the consultancy division was merely a part ex-over should have been aware of the dangers of unmodified acmp our second group is led by Harley also

00:39:15 our second group is led by Harley also untroubled by compliance Harley's subcontractor designer Mr Lam failed to check whether acmp was compliant with the functional requirements and ADB and did not even

00:39:27 requirements and ADB and did not even read the BBA certificate Holly seeks to limit the importance of its role to Mere cladding subcontractor but the letter of intent against which it worked recorded the subcontract was

00:39:39 it worked recorded the subcontract was for the design of the facade works it avails hardly nothing to suggest as it does that it was merely a labor-only subcontractor as opposed to a designer

00:39:51 subcontractor as opposed to a designer nor is it of great significance that the contract was not signed it was clear from the documents Ryden and Harley exchanged that a contract for the design of the cladding had been made and the

00:40:02 of the cladding had been made and the price agreed Harley clearly undertook a degree of design by its Mr Lam as such Harley owed a duty to warn if the NBS specification was patently defective

00:40:14 was patently defective second in our group 2 lineup is Ryden who was design and build contractor clearly had a responsibility to at least check compliance of the facade but failed to do so and also selected the

00:40:27 failed to do so and also selected the upvc window surrounds which permitted the fire to escape so easily third in group two is rbkc building control

00:40:37 control whilst the disaster would not have happened without the acts and emissions of the construction professionals and manufacturers it is conceivable that it could have been avoided if building

00:40:48 could have been avoided if building control had identified the non-compliance of the cladding system that said building control is only likely to have noticed the insulation was non-compliant and even it had it

00:41:01 was non-compliant and even it had it required a change to Mineral wall the disaster would still based on the phase II experiments have occurred Ms Menzies however considers Hoban should have interrogated the BBA

00:41:14 Hoban should have interrogated the BBA certificate and established that the panel chosen at grenfell was not class zero

00:41:20 zero even had Hoban identified both non-compliances it is likely given the permissive nature of building regulations and given the design team's Financial motivation to use acmpe that

00:41:33 Financial motivation to use acmpe that the team would have persuaded Hoban the design complied by some way other than compliance with the linear route possibly by desktop dclg's Martin was after all

00:41:45 dclg's Martin was after all contemporaneously concerned that bcos would be swayed by dubious desktops whilst the contractors and designers all claim it was building controls role to

00:41:56 claim it was building controls role to be the final Arbiter of whether compliance had been achieved this is neither sensible in Practical terms nor is it fair contractors and designers are generously

00:42:08 contractors and designers are generously paid to focus on whether the building including its facade is compliant whereas a local Authority has to consider many buildings and its staff are necessarily not the same caliber as

00:42:21 are necessarily not the same caliber as highly paid highly specialized designers and contractors historically the courts have considered local authorities are not Underwriters of building projects and that seems

00:42:32 of building projects and that seems correct

00:42:33 correct whilst we do very much criticize our bkc building control we do not consider they're as culpable as the manufacturer architect fire engineer and contractors

00:42:44 architect fire engineer and contractors last in our group 2 lineup is government clearly as the department for leveling up admits the department facilitated the disaster but the real questions are

00:42:55 disaster but the real questions are whether the department could and should have acted earlier and if it had whether it would have prevented the disaster given the many deceptions practiced by industry to circumvent even those

00:43:06 industry to circumvent even those elements of ADB which were clear some of these deceptions came even after grenfell showing some industry protagonists unswerving commitment to

00:43:17 protagonists unswerving commitment to circumventing inconvenient regulation these practices included manufacturers deceptive marketing extending to corrupting BBA certificates the

00:43:28 corrupting BBA certificates the production of self-serving guidance such as tgn18 using desktops to circumvent adb's linear and test routes Kings fans post-grenfell myth busting campaign against non-combustible products and

00:43:41 against non-combustible products and nhbc's 2016 guidance approving A build-up of acmp and combustible insulation I now turn to responsibility for exacerbation of the consequences of the

00:43:53 exacerbation of the consequences of the fire

00:43:54 fire primary responsibility for This falls into two categories those who caused or contributed to poor compartmentation and those who failed to ensure adequate means of Escape for those with

00:44:05 means of Escape for those with disabilities as to compartmentation failures these are attributable to a variety of factors including doors the installation of the gas pipe in the stairwell and breaches

00:44:17 gas pipe in the stairwell and breaches in compartmentation caused by the smoke control system responsibility for lack of operational door closers falls on rbkc and TMO there

00:44:28 door closers falls on rbkc and TMO there was no system of planned maintenance or routine inspection of the doors and rbkc's Laura Johnson rejected an annual door closer inspection program on grounds of cost despite lfb having

00:44:41 grounds of cost despite lfb having required it this conscious cost benefit analysis with human life as the cost was not a legitimate way for a local authority to behave

00:44:52 behave Johnson should have sought increased funding and stress to her superiors that gravity of the situation tmos simply went along with rbkc despite

00:45:03 tmos simply went along with rbkc despite understanding the importance of a door maintenance regime to Life Safety TMO also Bears responsibility for failure to ensure rectification of

00:45:14 failure to ensure rectification of unsealed holes in the compartment walls made by pipes for the new gas supply about which it had been warned the designer of the smoke control system

00:45:25 the designer of the smoke control system PSB Bears responsibility for breaching compartmentation via the North and South shafts of the system the sb's failure to appreciate that the shafts were protected shafts is a

00:45:37 shafts were protected shafts is a fundamental and serious issue compounded by PSB specification of substandard dampers

00:45:44 dampers the dampers should have been smoke control dampers but instead were fire dumpers the lowest possible standard the panel should disregard psb's attempt

00:45:55 the panel should disregard psb's attempt to blame lack of clarity in the regulations and to assert that functional requirement B3 does not extend prevention of smoke within or from the protected shafts Dr Lane was

00:46:08 from the protected shafts Dr Lane was clear that the dampers were required to be smoke dampers the second way the consequences of the fire was exacerbated is perhaps one of the most important lessons grenfell

00:46:20 the most important lessons grenfell teaches us namely the failure principally by exover and Studio e to ensure adequate means of Escape for disabled people X over and Studio e failed to ensure

00:46:32 X over and Studio e failed to ensure that grenfell was designed in accordance with the principles of inclusive design contrary to ADB ex-over's Witnesses were strident that ADB did not require means of Escape for

00:46:44 ADB did not require means of Escape for disabled people in general needs residential buildings as a result ex-over's fire safety strategy was silent on means of Escape for disabled people and worse repeated

00:46:56 for disabled people and worse repeated the misdescription of the lifts as firefighting lifts despite X over having been told by Mr Suns that they were not Dr Lane was clear that ADB required

00:47:07 Dr Lane was clear that ADB required means of Escape for disabled people and that the description of the so-called evacuation lift in stokes's fras should have prompted X over to consider means of Escape for disabled people

00:47:18 of Escape for disabled people instead exover simply assume disabled people would evacuate or at worst wait in the stairwell until the fire has been put out

00:47:28 put out it is troubling that an allegedly world-class fire engineer in the 21st century could consider such an approach acceptable given it involved an abdication of ex-over's Duty as fire

00:47:41 abdication of ex-over's Duty as fire safety engineer to ensure people's safety and Fire this is a classic example of an industry professional blaming the regulator for something which is not a weakness in the

00:47:52 something which is not a weakness in the regulation but the professional's own ignorance or willfulness Studio e was aware of the inclusive design requirement and the presence of

00:48:03 design requirement and the presence of disabled people in grenfell hence soon's commissioning Bonnet Associates to consider access in stage e the resultant accessible design guidance was however silent on egress contrary to

00:48:16 was however silent on egress contrary to ADB

00:48:17 ADB Studio e simply assumed the vulnerable would take refuge in Flats on the same floor but without verifying that assumption this failure is made worse by students

00:48:29 this failure is made worse by students awareness that the lifts were not firefighting lifts he claimed he may have been confused about this in that he knew it was not a firefighting shaft but that alone should have caused him to

00:48:40 but that alone should have caused him to ascertain whether the lifts were firefighting lifts means of Escape for disabled people would have been uppermost in ex-over and Studio E's Minds as prior to grenfell

00:48:53 Studio E's Minds as prior to grenfell ex-over provided for disabled evacuation in its fire safety strategy for the neighboring Kensington Leisure Academy Leisure Center ex-over and Studio E's failure at

00:49:04 ex-over and Studio E's failure at grenfell was exacerbated by the failure of others our bkc had been a Trailblazer for accessible housing and had received advice in 2010 and 2012 that those with

00:49:15 advice in 2010 and 2012 that those with disabilities being housed on the ground floor or a refusal to house them was a failure to comply with ADB rbkc was also aware that those with

00:49:26 rbkc was also aware that those with disabilities might take up to four times longer to evacuate yet it did not ensure grenfell its Flagship renovation project provided adequate means of Escape for disabled people

00:49:38 disabled people TMO also failed despite being acutely aware of those with disabilities in grenfell to ensure the refurbishment provided adequate means of escape and made things worse by knowingly

00:49:50 made things worse by knowingly misdescribing the lifts as firefighting or evacuation lifts Stokes the fire risk assessor also further the dangerous impression that the lifts were firefighting lists and

00:50:01 the lifts were firefighting lists and stated grenfell had reasonable arrangements for the evacuation of disabled people he fell below the standards Lane considers were required of him

00:50:11 of him finally government also Bears responsibility for the failure to ensure means of Escape for disabled people were fully explained in ADB undoubtedly ADB

00:50:23 fully explained in ADB undoubtedly ADB required inclusive design but as explained in our module 6 submissions government had been aware from 2004 that means of Escape guidance was inadequate and from 2015 at latest that the

00:50:35 and from 2015 at latest that the guidance was widely regarded as insufficient to conclude those we consider primarily at fault for the disaster had or ought to have had specialist knowledge and

00:50:47 to have had specialist knowledge and were in a position to alter the outcome by deploying that knowledge in the interests of safety one of the inquiries most important tasks is to bring about a sea change which instills both within government

00:51:00 which instills both within government and across the sector the importance of fire safety burden that they bear this requires an appreciation that the built environment poses a danger to end

00:51:11 built environment poses a danger to end users not only to work when working within it a risk which has largely been cured by the CDM regulations if the inquiry can affect the sea change

00:51:23 if the inquiry can affect the sea change it will be a turning point in the industry's long history those most missiles thank you very much I understand where we're going to hear also from Mr

00:51:34 we're going to hear also from Mr Friedman is that right yes with freedom you come up when you're ready

00:52:03 while grenfell Tower still burned this inquiry was established the urgency reflected the scale of the disaster still one of the most fatal known cladding fires anywhere in the

00:52:14 known cladding fires anywhere in the world

00:52:16 world since then the inquiry has revealed an industry of Manufacturers Architects and contractors who were allowed into grenfell Tower by the council owner and its agent

00:52:27 the council owner and its agent you will be in a position to describe wrongs done in relation to design materials engineering and management you will have the detail of the

00:52:38 you will have the detail of the instability of the various regulatory regimes which state act has tolerated and corporate actors capitalized upon you will now know just how out of its

00:52:50 you will now know just how out of its depth emergency response to catastrophic events was and still would be in the major cities of this country particularly firefighting but more generally disaster management

00:53:02 generally disaster management and you will have come into contact with people and the community the social high-rise building in its surrounding area

00:53:11 area their disaster began with how they were treated by rbkc and the TMO before the fire and continued through to an aftermath where they were left to build their

00:53:22 where they were left to build their lives back up from nothing

00:53:26 grenfell's victims and some of its perpetrators come from all over the world

00:53:32 world but this disaster was made in Britain without detracting from what you have just heard as to where discrete responsibility lies it is important to ask what is it about

00:53:44 it is important to ask what is it about modern Britain that allowed the grave wrongs of Industry to take root for the emergency response to crash and for its socially housed population to be treated as objects and problems rather

00:53:57 treated as objects and problems rather than people with rights worthy of respect

00:54:01 respect one of the few places in British Society where those types of social contact questions can be rightly asked and legitimately answered is a public

00:54:12 legitimately answered is a public inquiry

00:54:14 inquiry inquiries are commissioned by government but they are for the public they are not trials or ordinary legal processes

00:54:22 processes the panel properly investigates policy governance economics in a manner beyond the means and purpose of ordinary courts unlike civil and criminal proceedings an

00:54:34 unlike civil and criminal proceedings an inquiry can adopt flexible standards of proof paper and oral analysis and engage in fact finding that there's not only arise from direct causation of events that identifies context contributing

00:54:47 that identifies context contributing factors and broader matters of system and culture an inquiry cannot make determinations of civil or criminal liability yet it can pave the way for both

00:54:59 yet it can pave the way for both you have heard the bsrs call for justice one part of that Justice is in this process of publicly accountable learning

00:55:10 process of publicly accountable learning in an inquiry concerning Mass Fatality and plot complex technical investigation it would be wrong ever to lose sight of those who died so too would it be wrong to ask for the

00:55:22 so too would it be wrong to ask for the bereaved to undergo yet further proceedings after the conclusion of your work to obtain findings about the depths of their loved ones that is why the inquiry agreed at its outset to do its best to establish who

00:55:35 outset to do its best to establish who when where and how each individual died and to place those facts in the context of the causation and circumstances of the fire

00:55:44 the fire the reporting of the module 8 presentations and their cross-reference to the inquiry's findings in the other phase two modules will be the final part of that endeavor inquiry has also invited submissions on

00:55:57 inquiry has also invited submissions on recommendations where the nature of a potential recommendation justifiers justifies him there should be further expert opinion and a public hearing to ensure

00:56:08 and a public hearing to ensure transparent ventilation of the issues the panel does not need me to tell it that robustly testing and explaining inquiry recommendations is key to their

00:56:19 inquiry recommendations is key to their success but it goes beyond that inquiries function to correct features of governments that cannot necessarily be trusted to correct themselves

00:56:31 be trusted to correct themselves it is an important part of the inquiries remit to draw out vested interests and opposition to essential change and to publicly dismiss unwarranted objections the alternative is that such objections

00:56:43 the alternative is that such objections only surface later behind closed doors and we've quite within corridors of power

00:56:48 power it is a root cause of This Disaster that it's subject matter from construction to residents rights has never evolved on an open equal and accountable playing field

00:57:00 open equal and accountable playing field to regain trust things must be different now

00:57:06 when one hears of The Reckless and at times predatory behavior of those responsible for the fire and its spread it inevitably begs The Wider question what type of society allowed this to

00:57:20 what type of society allowed this to happen

00:57:21 happen on this we offer seven observations first

00:57:27 first we live in a particular type of post-industrial risk society in which advances in science and technology with all their possibilities also generate threats

00:57:38 threats this paradoxical Dynamic of modernization is aggravated by globalized processes that expose us to materials made and tested in one country sourced in another lawyered in a third

00:57:51 sourced in another lawyered in a third and then installed in and onto buildings by multiple contractors second

00:57:57 second when we fail to properly consider low statistical risk events with foreseeably devastating consequences we particularly expose ourselves to disaster

00:58:08 expose ourselves to disaster as Professor torreiro put it foreseeable risk must always be multiplied by the enormity of consequence especially so when the chance of the event happening was actually increasing as it was with

00:58:20 actually increasing as it was with cladding fires the LGA guide statistics on the low number of evacuations from high-rise blocks in the is the inquiries now well-known example of a false Council of

00:58:31 well-known example of a false Council of security it took no account of severity overlooked near misses assumed no Under reporting and left out local and international knowledge on the very danger it offered Assurance against

00:58:45 danger it offered Assurance against third

00:58:46 third in disaster risk analysis complacency about what is Normal and abnormal is inherently problematic and the misdirection and miseducation of

00:58:57 and the misdirection and miseducation of the lfb is a case in point at a normal incident almost every one of the failings in lfb's competency at grenfell Tower would not have mattered

00:59:08 grenfell Tower would not have mattered standard compartment firefighting with little incident command or communication would have sufficed what events like grenfell show is that a risk-related service that knows only the

00:59:19 risk-related service that knows only the bounds of past or frequent experience will be fragile in the face of what is unexpected and new this predisposition to normalcy undid the lfb on the night of the fire

00:59:32 the lfb on the night of the fire but it is no doubt something that affected other bodies studied by this inquiry across its modules fourth

00:59:42 fourth fundamental weaknesses in the relevant regulatory regimes were not acted upon as they should have been other submissions have dealt with building regulations building control

00:59:53 building regulations building control and the circumvention of testing and certification to that we add that fire safety enforcement and emergency response lagged far behind in their understanding

01:00:04 lagged far behind in their understanding and capacity to respond to contemporary building challenges and we're not even close to being up to the job of deterring detecting and punishing non-compliance

01:00:15 non-compliance you have seen that competency was compromised by the inferior status of fire Engineering in general as an academic and Vocational discipline within lfb organizational culture

01:00:27 within lfb organizational culture manifested in a way where there was a particular disconnect between the fire safety department and station-based or operational firefighting the resulting instability in the regime of itself

01:00:39 instability in the regime of itself should have caused government to identify the risk of high-rise residential fire as an issue of national resilience instead civil servants and the local fire Services managers held an

01:00:51 the local fire Services managers held an unwarranted belief that the notorious cladding fires in locations like Dubai were not going to happen here our fifth Point concerns localism and

01:01:02 our fifth Point concerns localism and deregulation the political imperative to devolve power and responsibility from a centralized state in order to unencumber public services and businesses from

01:01:13 public services and businesses from regulatory restrictions is not new however the post-2010 politics of the coalition government produced a civil service mindset that was deeply resistant to Progressive reform and

01:01:25 resistant to Progressive reform and overly beholden to the private sector aside from the unreconstructed fate of the building regulations there were other damaging consequences for example

01:01:36 other damaging consequences for example the Machinery of central government dedicated to fire safety was comprehensively scaled back in terms of its Civil Service expertise oversight and Leadership local fire Services lacked external

01:01:48 local fire Services lacked external scrutiny and challenge recommendations to review fire safety and operations most significantly after the Latino house fire were not implemented even following undertakings to do so

01:02:00 to do so National high-rise firefighting policy via the revised gra 3.2 was chaotic in its drafting irresponsibly devolved to the local fire services and constitutes

01:02:12 the local fire services and constitutes a further series of missed opportunities one to acknowledge the risk posed by cladding fires two to query the inflexible Reliance on stay put and free

01:02:23 inflexible Reliance on stay put and free to review the Manifest dangers posed by the do-nothing advice in the LGA guide on the issue of evacuation of vulnerable persons all these risks were foreshadowed none of them were addressed

01:02:36 foreshadowed none of them were addressed six

01:02:38 six the inquiry is learned of a host of public sector services in Decline including the privatization of the management of local Authority housing and the degraded function of its

01:02:49 and the degraded function of its building control the long-term cause lies in political decisions to roll back State services and various iterations of free market economics again neither began in 2010

01:03:03 economics again neither began in 2010 but Beaufort accelerated as part of austerity politics following the global financial crash in 2008. and rbkc it is fair to say aligned

01:03:16 and rbkc it is fair to say aligned itself with both that politics and its economics

01:03:19 economics however

01:03:20 however the causes of decline can also be found in the shortcomings of organizational life

01:03:26 life the inquiry study of the lfb shows the 20th century service that is structurally and culturally ill-suited to 21st century challenges there are basic deficiencies in

01:03:38 there are basic deficiencies in management competence necessary reforms that have been repeatedly and cyclically identified in reports spanning 30 years have been institutionally resisted

01:03:49 have been institutionally resisted training when done replicates past practice and ignores advances in fire science Clinical Psychology and genuine integration of the control room into an

01:04:01 integration of the control room into an incident response there is over politicization of service issues with a management Union divide that obscures the traditional monoculture of the service and its

01:04:14 monoculture of the service and its outdated methods a more mundane function of localism in the is that political responsibility for the lack of Reform is pinned on local authorities and chief officers

01:04:26 officers as a result of no formal expect inspection for more than a decade this state of affairs was left unacknowledged and unchallenged until responsibility for Fire and Rescue Services moved back

01:04:37 for Fire and Rescue Services moved back to the home office in 2016 in 16. successive governments regarded themselves as positively virtuous in not intervening our seventh point is that the UK has no

01:04:51 our seventh point is that the UK has no disaster management system the regime under the Civil contingency act 2004 wages preparedness for disaster on the postcode Lottery of the approach of Any Given local Authority that regime

01:05:05 of Any Given local Authority that regime collapsed at grenfell When The Fire And aftermath were in one place rbkc was both overwhelmed and fundamentally compromised by its long disengagement from affected communities

01:05:16 disengagement from affected communities and its obvious conflict of interest as the owner of the building the necessary integration between central regional and local government and other statutory responders floundered for three days while the

01:05:29 floundered for three days while the council carried on unwilling to admit its incompetence and lack of authority in the absence of an external inspectorate system for emergency planning rbk's weaknesses were unknown

01:05:42 planning rbk's weaknesses were unknown the London Regional system was labyrinthine overly horizontal and duplicating but most importantly had no power to intervene in rbk City without

01:05:53 power to intervene in rbk City without invitation to do so that's the central government the best description remains that of Professor Clive Walker that it is a ghost in the machine under part one of the

01:06:04 machine under part one of the legislation dealing with local emergency the government does too little under part two which has never been used it takes over between those two extremes there are neither sufficient powers nor

01:06:16 there are neither sufficient powers nor duties to scale up when the nature of the local crisis requires as it did so much here

01:06:25 failure to prayer prepare for disaster matters not least because when disaster strikes it's invariably impacts hardest on those least able to cope failing to prepare therefore becomes a

01:06:38 failing to prepare therefore becomes a denial of equal protection that is why we have often pressed for the panel to inquire beyond the essential immediate technical causes and circumstances of the fire

01:06:49 circumstances of the fire what this inquiry has ended up learning goes to the most fundamental questions that Society must ask itself the common feature of the evidence cutting through all modules is how

01:07:02 cutting through all modules is how little the fate of Ordinary People mattered when key decisions were taken people either did not factor in the equation at all or they were objects without agency

01:07:13 without agency statistics profit beneficiaries the crowd

01:07:18 crowd what happened to dsbsr was born of a failure of human accounting a point that Council to the inquiry felt bound to express at the conclusion of modulates

01:07:29 express at the conclusion of modulates we say that it does not have to be this way

01:07:33 way firstly

01:07:35 firstly Beyond left and right politics it is essential to bring the concept of the state out of its long ideological eclipse and ask Anew how can it act as a

01:07:47 eclipse and ask Anew how can it act as a source of common good the timeline for the eclipse is generally regarded as beginning in the 1980s

01:07:54 1980s subsequent conservative and labor administrations limited the role of government in contrast to the era after 1945 when it played a more significant part in welfare and planning

01:08:07 part in welfare and planning we are still in the era of the robed back State and grenfell is one of its greatest failings Center of government particularly the ministries of everyday life like housing

01:08:19 ministries of everyday life like housing Fire and Building has been hollowed out with the numbers of civil servants reduced ministerial responsibility diminished and decisions between subject

01:08:30 diminished and decisions between subject matter experts shed with all these diminutions the capacity to act to prevent and respond to a disaster of this nature was lost inevitably Market forces and

01:08:43 inevitably Market forces and malpractices have filled the gap that is the Paradox of the free market when the state leaves the government's vacuum of a powerful organizations and actors will seek to take advantage and

01:08:56 actors will seek to take advantage and usually for their own benefit rather than the public good a second defining feature of the relationship between State and Society since the 1980s has been to increasingly

01:09:08 since the 1980s has been to increasingly disconnect economics from Collective morality

01:09:13 morality the disconnection is pertinent to the times when relevant grenfell decision makers resorted to commercial cost analysis without properly including in the balance the value of human life and

01:09:24 the balance the value of human life and safety

01:09:25 safety the inquiry will have in mind one Laura Johnson's decision in March 2017 to have no door closer inspection regime at all rather than taking emergency action to

01:09:38 rather than taking emergency action to alleviate a known long-term estate-wide fire safety danger the TMO stood by the lfb let the matter go two

01:09:49 two Colin Todd and the commissioners of the LGA guides justification for doing nothing to meet the fire safety needs of vulnerable persons was made on the basis of common practice of trade without

01:10:03 of common practice of trade without considering its moral and legal implications three

01:10:08 three civil service and ministers allowed the time scales for review of a few of document B to repeatedly slip over years despite knowledge of its flaws with Brian Martin conceding that what

01:10:20 Brian Martin conceding that what government was trying to do was to balance cost of Regulation with its benefits so the industry was Freer to improve the economy

01:10:31 improve the economy even if Improvement in his sense was at the price of weakened fire safety standards

01:10:39 standards all these decisions reflect a prevalent learned bureaucratic ethos and culture that prioritized what things cost in the most economic narrow sense to the

01:10:51 most economic narrow sense to the exclusion of what they were worth economics needs to be reclaimed as a dialogue about moral as well as Financial well-being

01:11:01 the instances of actual engagement with residents before during and after grenfell is a Chronicle of disempowerment before the fire they were subject to

01:11:14 before the fire they were subject to institutional bias and Prejudice the attitude of rbkc the TMO and their contractors was that people should be thankful for what they got or be ignored even targeted or maligned

01:11:26 even targeted or maligned this was a relationship of Master servant that has no place in a modern democratic Society critical to the ill treatment was that important information relevant to

01:11:37 important information relevant to resident safety was deliberately kept from them and collectively they were repeatedly denied a voice than during the fire without any foundation in research experience or

01:11:49 foundation in research experience or training the possibility that neighbors might act in a rational and collaborative manner when escaping from the building they knew was discounted after the fire

01:12:00 after the fire when local government collapsed the displaced Community reconstituted itself in the surrounding streets but not before different levels of government saw the situation primarily as a threat to public order

01:12:12 to public order the primary motive of civil contingency response in those first seven days of aftermath was security and containment not compassion for human welfare

01:12:25 responsibility for risk-based decisions such as these will often have a technical Dimension dependent on expertise and the Judgment of appointed officials delegated contractors and

01:12:38 officials delegated contractors and elected representatives that cannot mean that people who bear the consequence can be excluded or disregarded utilizing the insight and experience of

01:12:49 utilizing the insight and experience of those affected by decisions is always in the service of better outcomes and makes obvious good sense and shows due humility

01:12:58 humility but it goes beyond that without dilucating legal duties effective engagement with residence is essential to demonstrating respect for them as equals even if respective roles differ

01:13:10 equals even if respective roles differ none of us would accept otherwise for ourselves or our loved ones why should BSR have been different

01:13:21 we say much of the answer to that lies in social inequality the fire disproportionately killed people with disabilities

01:13:32 people with disabilities those of Middle East African and other migrant background and those living in social housing the high number of deaths amongst disabled residents at grenfell is a

01:13:43 disabled residents at grenfell is a landmark fact of This Disaster but it is yet to be acted on the LGA guide which not just permitted but positively encouraged those with fire obligations to do nothing to prolan

01:13:56 fire obligations to do nothing to prolan or provide for The Escape of such persons is unchanged on the eve of the fifth anniversary of the fire the home office pivoted from implementation of the inquiries phase one recommendations on personal

01:14:09 one recommendations on personal emergency evacuation plans that had been supported by an overwhelming proportion of consultees to its current ill-conceived proposals shockingly the government would not only

01:14:21 shockingly the government would not only disregard the lessons of the fire but would water down existing protections the proposals do not apply to stay put buildings at all they would not impose any legal Duty on responsible persons to

01:14:33 any legal Duty on responsible persons to put in place an evacuation plan they are inexplicably limited to persons with Mobility impairments and they would Place primary responsibility for enabling escape on the fire Services

01:14:44 enabling escape on the fire Services contrary to both long-standing principle and all the inquiry evidence of FRS incapacity and incapability at least at present time that leads to our emphatic plea

01:14:57 that leads to our emphatic plea the inquiry must issue an urgent interim report to leave the government in no doubt as to why the intransident do nothing status quo is dangerous and in violation of current law under the rro

01:15:09 violation of current law under the rro and applicable human rights this inquiry combining legal Authority evidential wisdom and objectivity is uniquely based to incontrovertibly say

01:15:21 uniquely based to incontrovertibly say this waiting until the publication of your final report is too late

01:15:29 the national ethnic and cultural backgrounds of those who died at grenfell tower Tower has in itself always called for further reflection on

01:15:40 always called for further reflection on the issue of race despite the diversity of London the evidence heard across the modules has been of an absence of Engagement with the implications of race or religion by

01:15:51 the implications of race or religion by relevant public authorities whether in terms of linguistic cultural or other implications at best this shows an unhealthy lack of curiosity about the needs and experience

01:16:04 curiosity about the needs and experience of an important body of service users but it needs to be seen as part of a broader syndrome the fact is that every inquiry module has revealed serial ignorance and

01:16:16 has revealed serial ignorance and non-compliance with the public sector equality Duty by all relevant public qualities across all relevant protected characteristics even where the issues cried out for attention to the statutory

01:16:29 cried out for attention to the statutory or quality equality objectives the important purpose of the duty Trace back to the Stephen Lawrence inquiry report and the problem of institutional in that case race discrimination within

01:16:43 in that case race discrimination within the public sector meaning disadvantage caused by unwitting Prejudice ignorance thoughtlessness and stereotyping it is important for this inquiry to

01:16:54 it is important for this inquiry to robustly reaffirm the value of the public sector equality Duty in the context of this Mass disaster and to consider recommendations directed to its future effective embedding assurance and

01:17:05 future effective embedding assurance and enforcement Beyond this the socioeconomic Duty in section one of the equality act in fourth in Scotland and Wales but not yet

01:17:17 fourth in Scotland and Wales but not yet in England offers an obviously pertinent and promising legal tool to combat the institutional socio-economic socioeconomic discrimination experienced by grenfell residents and those living

01:17:29 by grenfell residents and those living in social housing we urged the inquiry to say as much

01:17:35 can we conclude by asking

01:17:39 by asking what effective change looks like This Disaster is about the failure of the duty of care in its broadest sense legal political and social

01:17:53 legal political and social the question of who is my neighbor person posed nearly a century ago by Lord Atkin in the case of Donahue and Stevenson and what this should mean in

01:18:04 Stevenson and what this should mean in terms of legal duties and social values calls for re-evaluation and evolution in our modern risk Society the legacy of grenfell must be to intensify duties between State

01:18:16 intensify duties between State organizations and people in the main areas of building and fire safety the duty of care require legislative reform tougher regulations new offenses higher penalties

01:18:28 new offenses higher penalties however

01:18:29 however well-designed laws are not enough they cannot work without sufficiently competent and properly resourced enforcement which will not exist in Britain without a fundamental change in

01:18:40 Britain without a fundamental change in education and accreditation across a range of disciplines law and policy can quickly become out of date due to design Innovation or cynical circumvention

01:18:52 circumvention laws can always be amended so as to stall or roll back protections perhaps especially so in areas of risk lying outside the public gaze where the lessons of the past are most liable to

01:19:04 lessons of the past are most liable to be sidelined or forgotten and so safeguards must be embedded into organizations and systems to enable us to trust them more on this we highlight three

01:19:17 on this we highlight three first

01:19:18 first the statutory duty of Candor could serve as an essential constitutional Innovation provided it applies to public authorities and private bodies contracted to do public works as well as

01:19:31 contracted to do public works as well as those whose products or Services have implications for the health and safety of the public even then

01:19:39 even then many of the organizations studied by this inquiry are not self-countable and therefore would find it difficult to be truly candid and Frank without significant changes in organizational

01:19:50 significant changes in organizational culture and ethics second a national oversight mechanism as long advocated by the organization inquest which served to break the

01:20:02 inquest which served to break the current lamentable pattern of unlearned lessons and repeated failure to act on recommendations to prevent future debts which includes of course the promptly lost lessons of Lucknow house

01:20:16 lost lessons of Lucknow house and third

01:20:17 and third the relationship between bureaucrats experts technicians and those they serve requires a reset so that people affected by risk-based decisions who in some

01:20:30 by risk-based decisions who in some cases must live or die with the consequences are duly informed engaged with and listened to but legal Innovations are doomed to fail

01:20:42 but legal Innovations are doomed to fail absent wider societal transformation of existing ways of doing things grenfell was a human rights disaster a systematic failure of state and

01:20:54 a systematic failure of state and private actors to protect the life security and dignity of people there are undoubted individual wrongdoers in this tragedy but there was also wider institutional and societal

01:21:07 also wider institutional and societal indifference that allowed them to act with impunity what happened at grenthal Tower demonstrates an essential problem with the way the golden rule of faith and

01:21:18 the way the golden rule of faith and ethics is applied that we don't necessarily do unto others as we'd have them do unto us when we do not or cannot conceive of being in their position

01:21:30 position we need not imagine that their home could be our home we do not appreciate the Empower imbalances they endure we do not live by the premise and in all

01:21:42 we do not live by the premise and in all of life's profit and loss we are ultimately Neighbors the evidence painstakingly assembled and heard by this inquiry tells us that we must

01:21:58 thank you very much Mr Friedman

01:22:10 the next closing statement is going to be made by Mr Michael Mansfield King's Council on behalf of again the brief survivors and residents whom he represents

01:22:45 yes restaurant sales good morning uh

01:22:51 uh okay

01:22:52 okay sorry Stefan Ali Akbar

01:22:57 since I'm going to close the file and I'm going to speak as it were hopefully from both the heart and the mind

01:23:08 mind because I'm treading a rather treacherous path here I don't want to repeat any of the very fine words that already been spoken which we endorse as team too

01:23:20 which we endorse as team too I don't want to repeat matters that you've read in our written submissions on this as well are there detailed as you've seen

01:23:31 well are there detailed as you've seen but I want to as it were touch on

01:23:36 touch on the themes that are already emerging merging

01:23:42 Stephanie Barbers talked about in a sense both speakers talked about the necessity for a sea change

01:23:53 the necessity for a sea change in approach a society which we don't live in at the moment

01:24:00 moment and in fact is at risk of deteriorating even further

01:24:10 so behind all of this the theme that I want to start with is by just

01:24:17 by just flash a flashback of time it's easy to forget because the question I'm going to ask is I hope there isn't another one another

01:24:29 I hope there isn't another one another inquiry following another disaster in 50 years time where all the same points are being made because the assiduous manner in which

01:24:42 because the assiduous manner in which you have approached all of this and the patience that you have shown over the many weeks months and years now we'll go to waste unless

01:24:54 we'll go to waste unless there is a commitment because

01:24:57 because whether it's called a human rights disaster

01:25:01 disaster or characterized in other ways what happened was Criminal in the colloquial sense and in the legal sense

01:25:12 and this inquiry has begun obviously the process

01:25:15 process of of achieving some kind of justice but it's only the beginning and what I wanted to do is to just flashback for a moment

01:25:27 flashback for a moment as to why the significance of what you're about to embark on you may have thought that you've almost got there but in fact there is a further stage which I want to propose

01:25:39 in 1973

01:25:43 there was another disaster

01:25:47 it's forgotten

01:25:50 we certainly do need a national disaster plan

01:25:54 plan we need

01:25:56 we need a resource we need a mental capacity that remembers lest history repeat itself those who don't learn those lessons

01:26:07 it wasn't a high-rise maybe that's why it isn't thought about it wasn't on the mainland in the sense it was in the Isle of Man

01:26:20 a large number of people died and were injured

01:26:25 injured but the points that have been made this morning to you

01:26:30 a large number of them were all made then

01:26:34 then in another inquiry by another high court judge the country inquiry

01:26:45 it didn't take as long as this one but that's not the point the point was that they touched on the very same issues that asked now being touched upon

01:26:58 that asked now being touched upon issues to do with compliance because the three components that were put up on the facade of that building

01:27:09 put up on the facade of that building uh in a sense a high-rise entertainment center a prestigious project No Doubt none of the three complied interestingly

01:27:21 none of the three complied interestingly with legislation in the Isle of Man which

01:27:24 which prescribed the use of combustibles so question arose then as it does now how did they get around that law

01:27:35 how did they get around that law how was it permitted to happen then that there should be as it were cladding and the cladding burnt very fast and don't anybody say it's not the same planning

01:27:46 anybody say it's not the same planning but that's not the point that's what the academics try and say oh well there's a distinction it wasn't high rise it wasn't quite the same clothing but it was the same result

01:27:57 clothing but it was the same result because there was an unwillingness then it's developed since that time but that wasn't the only issue because the other issues discussed in

01:28:08 because the other issues discussed in the same breadth almost were to do with evacuation which is why a large number not because of there it wasn't a single staircase

01:28:22 of there it wasn't a single staircase point it was a a way in which there was open plan and there were too many people to get out and there weren't enough people who knew how to operate the evacuation procedures nobody had been trying to do it

01:28:34 been trying to do it so the similar sorts of points are coming up including sprinklers suppressants including fire extinguishers they had them but they didn't have

01:28:45 they had them but they didn't have enough trained people to use them now the these may seem in a sense of course because it's a long time ago but I raised them because

01:28:56 because unless there is the sea change that is being talked about there will be another inquiry following another disaster of this kind

01:29:09 another disaster of this kind and we we are going to phrase it slightly differently that what one's looking for here as a result

01:29:17 result of what kind of society and the sea change I think you yourself says to use the term during the hearing we're looking for a change in the mindset

01:29:30 looking for a change in the mindset a change in the culture that has pervaded many many years since 1973.

01:29:39 and that mindset is one in which a there are forces at work you've heard about they are political forces I began the opening in Phase One by

01:29:50 I began the opening in Phase One by reference to the red tape initiative which was meeting on the very morning of the fire

01:29:55 the fire meeting in order to see if it was possible to disassemble regulations so a very strong political stream of thought

01:30:06 thought set against obviously a much longer period of deregulation

01:30:14 so political forces are at work in this particular field economic forces of which you've seen cost benefit or the the power of profit

01:30:26 cost benefit or the the power of profit if I can put it that way as well so they're the economic forces that are at work but there are the social forces as well also at work which you've heard described this morning the social forces which are concerned with race

01:30:41 which are concerned with race with class with social housing all all of those merged together to form another Force that ensures that

01:30:53 another Force that ensures that the mindset we need to change what do we need to change it to

01:30:59 it needs to be changed going to put it into one proposition

01:31:06 it's one that is the theme of our submissions throughout phase one and phase two

01:31:12 phase two and that is fire safety first

01:31:18 it's a simple thought and a simple proposition but

01:31:23 but as Mr Freeman was just saying I think it's going to change unless there is a change in values unless there's a change in mental approach to these matters

01:31:34 to these matters how do you affect change

01:31:39 change and we say sir your inner and your colleagues are in I really

01:31:49 extraordinarily powerful position to affect change can I just interpose at this point how that might happen and I've I fear it

01:32:02 how that might happen and I've I fear it may be that you have already considered this please forgive me if you have but it's been hinted at this morning but I'd like to just develop it a little more

01:32:15 developing a little more means that of course it's it's not for us to say when your final report will be but we anticipate it certainly won't be this year and

01:32:26 year and um Sometime Late next year possibly earlier than that and we the enormity of the task is appreciated by all the families many of which are here today and they appreciate that the efforts

01:32:39 and they appreciate that the efforts that have gone in already and they're not as it were unappreciative at all but

01:32:45 but if the effects of what you have been doing for these years is going to be felt

01:32:53 felt then you have an opportunity to ensure that affect yourselves the suggestion we make for your consideration is that over the ensuing month

01:33:06 is that over the ensuing month at some point you issue an interim report that's been mentioned this morning it could be a series of interim reports in order that nobody is confused about what is

01:33:18 nobody is confused about what is intended within those reports

01:33:23 you specify recommendations and we know clearly you will make constructive far-reaching recommendations which you did after phase one or at the point of

01:33:35 did after phase one or at the point of phase one

01:33:37 phase one of which of course hasn't been implemented an important one already mentioned a a serious violation of Human Rights the Human Rights Act the

01:33:48 of Human Rights the Human Rights Act the equality act section 2 and section 14 read together almost ignored ignored on the basis and I I just again interposed this

01:34:00 interposed this the minister for fire safety House of Lords spring of this year an unimaginable I I hope this is not as

01:34:12 an unimaginable I I hope this is not as it were an exaggeration or as it were placing too much on a few words but it wasn't just it's not practical it's not proportionate it's not reasonable

01:34:24 not reasonable he actually used the simile that well the

01:34:29 the disabled might get in the way of the Able Body getting out of the building he didn't use those words but that was what he was saying

01:34:40 that was what he was saying that if anything demonstrates the depth to which our public life has descended never mind the Nolan principles which

01:34:52 never mind the Nolan principles which we've emphasized several times of which there are seven one of which being the duty of Candor which should be embraced we say as it shouldn't have to be why should we have to be thinking about

01:35:03 should we have to be thinking about legislation to try and set the agenda of candor

01:35:08 candor but that's in a sense where you and your your colleagues come in because in inter and interim report or a series of interim reports in which you specify

01:35:20 of interim reports in which you specify particularly important recommendations it's not being suggested for example that you would take time on what you regard as perhaps minor recommendations but major recommendations which will we

01:35:33 but major recommendations which will we hope have an impact on the approach of Industry on the approach of local government on the approach of central government and the approach of central government

01:35:46 and the approach of central government although there have been some concessions in that field perhaps I don't need to do more than mention one name

01:35:56 Lord pickles I don't need to spell out what he said and how badly he got it wrong

01:36:07 and how badly he got it wrong not misspeak Lord pickles it's indicative of a frame of mind now in those as it were attempts that I

01:36:18 now in those as it were attempts that I hope you might consider making you have the power under the inquiries act so it's entirely within the framework and again I don't need to spell that out you have a highly competent team of lawyers and advisors

01:36:32 competent team of lawyers and advisors and and any way you probably know but sections 24 and 21 allow you to as it were issue the report but you can also say we'd like answers

01:36:47 the importance of that is to find out publicly

01:36:51 publicly to what extent this is not going to be a report that is left

01:36:57 left to languish on a Dusty Shelf although no doubt digital these days

01:37:05 because that's almost what happened with the Isle of Man but I'll come back to what's happened on other occasions since then that's that's not the only

01:37:17 since then that's that's not the only one by a long way now this scheme that I'm suggesting that you you might consider involves the issue of the report and for a

01:37:28 the issue of the report and for a response

01:37:29 response you can monitor the response if you wish by suggesting to the recipients we'd like to know within 28 Days A Familiar phrase I've no doubt to many

01:37:41 Familiar phrase I've no doubt to many departments whether they can stick to that's another matter and they have a choice they can either not respond which will be made public or they can respond saying why they accept the recommendations and what they're

01:37:52 the recommendations and what they're going to do about it or they can say well we don't accept them and these are the reasons and then you can have if you wish

01:37:59 wish I know this must sound daunting this must sound for pitting you can have a further Hearing in relation to that with expert advice has already has been hinted at in relation

01:38:11 already has been hinted at in relation to that

01:38:13 to that this is extremely important for public confidence because one of the aspects of a public inquiry is the Regeneration of public confidence in the system because

01:38:24 public confidence in the system because no one can say anything other than Granville tar is the epitome of a complete collapse of a system not just a construction system

01:38:35 construction system but a system of governance which hasn't got the principles which I've already alluded to namely the Nolan principles now I'm saying all this not without

01:38:46 now I'm saying all this not without precedent because three other inquiries at the moment have inaugurated it's not exactly the same they each do it slightly

01:38:57 same they each do it slightly differently and obviously be a matter for your discretion whether you even do it at all but the infected blood inquiry are doing it as well as the Manchester Arena which

01:39:08 as well as the Manchester Arena which was only only part of it uh concl it was a report issued just before the weekend so these inquiries are doing it and and most of all the child abuse acquiry

01:39:20 most of all the child abuse acquiry and they're setting a time frame within which they require answers in writing and then hearings no doubt at some stage in public and we we say that that is

01:39:32 in public and we we say that that is perhaps one of the most important you may have thought the most important is already passed away in one sense it has because although the Granville Tower is still standing as we leave London on

01:39:44 is still standing as we leave London on the west side there it is as a monument bereft of life but the the communities that live there still stands the community that live

01:39:57 still stands the community that live there

01:39:58 there require this level

01:40:02 level of involvement in participation in a further stage as do the British public because

01:40:09 because as we've learned since there have been unfortunately during the currency of your

01:40:14 your your inquiry here other fires other fires where if I just pause for a moment on a recommendation peeps obviously we've put that

01:40:27 peeps obviously we've put that top of the agenda a priority part of the mindset

01:40:32 mindset fire safety first peeps right at the top how anybody can as it were humanely reject that but there are obviously other priorities

01:40:43 but there are obviously other priorities that follow one of them is and I've posed this once before if I were to go around the room here today and say first of all identify who lives in a high-rise and I know there are some

01:40:54 high-rise and I know there are some people in this room that do

01:40:57 if there's a fire in your block what do you do

01:41:01 you do what do you do what's the answer you would think by now since 1973 somebody would have thought of how to work this out it's not you know it's not as they say often a

01:41:13 you know it's not as they say often a sort of rocket science to work this out it it has to be tailor-made it has to be as it were building specific but on the other hand it's one of the things that the Lacon or

01:41:25 it's one of the things that the Lacon or coroner put first put first in her letter

01:41:31 to Lord pickles well and others there needs to be not just National disaster of plan of course there needs to be guidance this

01:41:42 course there needs to be guidance this is what she was saying on evacuation procedures so the answer to the question is most people don't know because there has been no National Guidance the London fire brigade perhaps have made strident

01:41:55 fire brigade perhaps have made strident steps towards at least a solution of a Kind otherwise we don't know any more than we did before how can this be so if for I give it as an example you do want

01:42:08 for I give it as an example you do want to make suggestions about in the context particularly of high rise because obviously where ladders can't reach where host bikes might not get where water pressure may not be sufficient all

01:42:19 water pressure may not be sufficient all the points you know about then

01:42:22 then they need to as it were at this moment in time if if you make that recommendation it needs to be as it were canvassed and it needs to be properly investigated as

01:42:34 it needs to be properly investigated as do other simple measures like the suppressants I've mentioned already namely spring sprinklers fire extinguishers but there are many others that you might want to do and and these

01:42:45 that you might want to do and and these these propositions are all constructive and and I just end this part of what I'm saying I'm looking at the clock carefully is that it is this that um

01:42:58 carefully is that it is this that um and the reason why I've taken time to emphasize this as you may know I I was I've been in Russian other in quite a certain many people here but particularly the Lawrence inquiry

01:43:12 another high court judge familiar to you or Justice McPherson very anxious he was that what he had to say what he

01:43:23 that what he had to say what he discovered over quite a long period not as long as this but over a course of nearly two years he was anxious that they were implemented and he kept saying this to

01:43:34 implemented and he kept saying this to various authorities that appeared in front of him that the 77 recommendations that he was in the end going to make about how matters could be resolved

01:43:45 about how matters could be resolved he didn't he didn't want them to rest on the Shelf but of course once you've issued the report there is no legal I hesitate to say as far as

01:43:57 I hesitate to say as far as current governments are concerned I suspect no moral obligation either to necessarily do any that is why the precursor of a procedure before you issue the final report is so significant

01:44:10 issue the final report is so significant because in Lawrence what happened was that the family

01:44:16 it wasn't obviously under the inquiries act but the family decided we say quite rightly

01:44:25 to engage in the process of ensuring implementation in other words they became what inquesters suggested they became the national oversight body for the proposals

01:44:37 for the proposals and what happened on a practical basis was that Mr and Mrs Lawrence hired the central Hall Westminster once a year for a number of years and

01:44:48 a year for a number of years and requested

01:44:50 requested and it was a request that was met the authorities the government ministers and others and police force Chiefs to attend

01:45:00 attend uh they would as it will have a book of Reckoning on an account they would ask well have you done these what about this one what about that one not expecting that they would all be

01:45:12 not expecting that they would all be implemented overnight but they were expecting

01:45:15 expecting some kind of feedback some kind of positivity some kind of recognition and that happened it still hasn't finished

01:45:26 it still hasn't finished but the process was begun by them or we say here

01:45:31 say here the families have said to you very clearly

01:45:34 clearly on many occasions Hanan wahhabi said it and others it lives every day they live with it this is not a forgotten tragedy

01:45:47 this is not a forgotten tragedy because they've lost a home and in many cases some cases a whole of a family

01:45:54 a family has

01:45:55 has in the flick of a finger gone therefore

01:45:59 therefore their anxiety is to ensure for the benefit of others that they don't have to go through this and this process that I'm suggesting to you might I hope

01:46:10 that I'm suggesting to you might I hope appeal to you because they just want to as it were emphasized too there are two quotations and only two I was going to ask for a document but I'm not going to to ask for

01:46:21 document but I'm not going to to ask for that

01:46:23 that but I do want to pray in a the the as it were the thoughts of

01:46:29 of um residents and occupants and and the way they have perceived long before anyone else

01:46:37 there was a meeting with residents later in 2017 in December where this was said by one of the residents I'm not going to name this

01:46:49 residents I'm not going to name this particular resident or any of the others for that matter because they speak with one voice

01:46:54 one voice and December 2017 this particular resident said what is clear here is that grenfell Tower was no accident

01:47:03 accident Grenville Tower was a catastrophic incident that should never have happened and was preventable Granville Tower happened due to the serious systems failure due to a culture

01:47:16 serious systems failure due to a culture of neglect I pause for a moment Grandville Tower was uninhabitable for 10 years because for example the

01:47:28 10 years because for example the ventilation system was beyond economic repair

01:47:31 repair it's not just an attitude to a building it's an attitude to occupants and he went on to say due to a culture of self-interest and due to the fact

01:47:42 of self-interest and due to the fact that residents were treated at certain times as second class citizens which is precisely why all the examples you've had in this inquiry are interestingly

01:47:54 had in this inquiry are interestingly and not coincidentally social housing knowsley Heights well you know them garlic caught and so on I don't need to go through them but the other matter which I wanted to I

01:48:07 but the other matter which I wanted to I don't ask for it to come up on screen I know you will have heard of it before because I've read passages in module three

01:48:16 three but I want it to end on it because

01:48:21 we hope this type of letter is never had to Rewritten again by the grenfold tower leaseholders Association in September

01:48:34 in September 2010 seven years before this fire relating to the conditions in grenfell Tower

01:48:45 it begins the passage I just it's in on the fifth page we are very shocked to learn from you that is the Royal Borough of Kensington and Chelsea TMO Under The Heading fire it's

01:48:58 Chelsea TMO Under The Heading fire it's a very long letter very considered letter health and safety we're very shocked to learn that you considered the defect in the building exposed by the fire as a minor fault

01:49:09 fire as a minor fault when it had potentially fatal consequence it wasn't a clouding fire that doesn't really matter what matters here as we know is the toxic fumes which can be traced back to the cladding and

01:49:21 can be traced back to the cladding and the esculation it's it's both have contributed to to that and he goes on to say they go on to say they they consider it a major fault but

01:49:35 when describing the conditions of evacuation the effect and impact of smoke because that's the cause of death in most of these cases in all of these

01:49:46 in most of these cases in all of these cases it may be difficult without the pathological evidence to go further than it's commensurate or consistent with exposure to fire however we would say

01:49:58 exposure to fire however we would say there's a very obvious inference that can be further than that it's toxic acrid black smoke staircases of the surrounding high-rise buildings are exposed to open air and natural light and so in case of a fire

01:50:11 natural light and so in case of a fire the smoke can easily Escape but Grenville Tower with its interior staircase malfunctioning ventilation system there is certainly a high probability that in the event of another fire the whole

01:50:23 the event of another fire the whole building can become an Inferno

01:50:30 1973 2010 when is somebody going to sit up and make the connections

01:50:40 and that is not happening because of the forces I mentioned at the beginning the political and economic forces that have to be counted and we would ask sir that this is the opportunity beyond measure

01:50:53 this is the opportunity beyond measure that you have and the families want to join with you in order to do that part of the suggestion that I've made and I haven't been through all the other matters where there's been a

01:51:04 matters where there's been a demonstrable failure and deplorable characteristics of arrogance complacency lies deceit all the way through those whenever I

01:51:15 all the way through those whenever I mention those words I'm sure a particular witnesses will be conjured up in your minds as to as it were representing those and we say this inquiry should end we hope on a positive

01:51:26 inquiry should end we hope on a positive note in which the families can stand alongside their Tower and say they've achieved something for later generations thank you well thank you very much Mr Manson well

01:51:39 well thank you very much Mr Manson well at that point we'll take the break for the morning uh we'll rise and we'll resume please at course to 12. thank you very much

02:08:01 foreign

02:08:07 now we're next we're going to hear from Mr Adrian Williamson King's Council on behalf of

02:08:13 behalf of his group of bsos uh thank you sir members of the panel uh it's now more than five years since the fire and more than four years since Mr

02:08:24 fire and more than four years since Mr Millet said this on the first day of phase one of the inquiry the fundamental question he said which lies at the heart of our work is how in London in 2017 a

02:08:35 of our work is how in London in 2017 a domestic fire developed so quickly and so catastrophically there's an entire high-rise block was engulfed and how it was that 71 people lost their lives in a

02:08:46 was that 71 people lost their lives in a matter of hours leaving hundreds without a home and for an inheritance an abiding sense of Injustice betrayal and marginalization leading to an overwhelming question why although we

02:08:59 overwhelming question why although we should now sadly substitute 72 for 71 in that quotation Mr millett's Question and the topics which he raised remain at the heart of this inquiry

02:09:10 heart of this inquiry following the publication of the phase one report the inquiry reconvenes in the January January of 2020 and on the first day of that hearing Mr Millet reminded

02:09:21 day of that hearing Mr Millet reminded all concerned that he had invited he said the core participants not to engage in a merry-go-round or buck passing but he said with limited exceptions that

02:09:34 but he said with limited exceptions that invitation had not been accepted and instead their case remained was that everything was someone else's fault as Miss barwise has explained this morning that largely Remains the case

02:09:48 morning that largely Remains the case now in this short presentation I'm going to discuss a number of aspects of the evidence which shed light upon the question why asked by Mr Miller's but

02:09:59 question why asked by Mr Miller's but before doing so I would like to make some general observations about the evidence you have heard in particular the expert evidence so far as that expert evidence is

02:10:11 so far as that expert evidence is concerned we team too have in general been impressed by the commitment shown by the inquiries experts and by the high quality of the work they have produced

02:10:23 quality of the work they have produced however the inquiry should be careful not to follow we would say two on questioning the unquestioningly the lead given by its experts however

02:10:35 given by its experts however distinguished in the end it is for the panel and not the experts to answer Mr millett's Question a good example of that is the testimony given by professors Torero and Bisbee as

02:10:47 given by professors Torero and Bisbee as to the experiments carried out in Edinburgh which formed work packages one and two

02:10:54 and two the important overall conclusion of this exercise was that was the ACM and not the insulation products which was the primary cause of the fire

02:11:05 primary cause of the fire a conclusion I think largely adopted by Miss bar wise this morning by contrast we would submit this an appropriate finding is that whilst the Rainer Bond PE was primarily responsible

02:11:19 Rainer Bond PE was primarily responsible for the rate and extent of fast spread during what has been referred to as quotes vertical far spread up close quotes both the ACM and the insulation

02:11:32 quotes both the ACM and the insulation can contributed to the far and it is impossible to say the exact proportions in which they did so we would say there are important reasons

02:11:43 we would say there are important reasons why the inquiry should proceed with caution in relation to the experiments and the conclusions to be drawn from first the experiments were conducted by

02:11:56 first the experiments were conducted by the inquiry experts alone and the core participants and their experts had no input into devising them or analyzing the results that is not to criticize the

02:12:09 the results that is not to criticize the professors or the inquiry such a procedure was no doubt unavoidable given the circumstances particularly the pandemic however such a unilateral

02:12:22 pandemic however such a unilateral approach is clearly far from ideal and would not be acceptable in litigation secondly and associated with that first point it is the case that the inquiry

02:12:36 point it is the case that the inquiry has not heard the views of other experts either upon the experiments or in relation to the causation issues generally

02:12:45 generally again that would not be acceptable in litigation nor have the inquiry's own experts been subjected to searching cross-examination as they would be in

02:12:57 cross-examination as they would be in high court proceedings thirdly the experiments carried out are Innovative and indeed untried the design and specifications of the

02:13:10 the design and specifications of the experiments have not been shared as yet with the wider fire expert community before other experts could accept the validity of the tests there would need

02:13:21 validity of the tests there would need to be more experimentation to understand what Professor Bisby himself describes as quotes the immense complexity of the heat transfer environment with a

02:13:32 heat transfer environment with a ventilated rain screen cladding cavity close quotes fourthly the experimental results obtained are limited to the experimental

02:13:44 obtained are limited to the experimental apparatus build size of about a meter given the small scale nature of the experiments in work package 2 and the absence of a whole system test it is

02:13:56 absence of a whole system test it is submitted that only limited conclusions can reasonably be drawn regarding the contribution of the insulation to the spread and intensity of the grenfell

02:14:08 spread and intensity of the grenfell tower fire uh we would also suggest that this inquiry needs to sup with a very long spoon when considering submissions from kingspan and others to the effect that

02:14:21 kingspan and others to the effect that the installation ultimately played no part in the fire after all Professor Bisby has concluded that the ease of ignition of k-15 and of RS 5000 might

02:14:34 ignition of k-15 and of RS 5000 might well be relevant to the initial growth of the fire outside flat 16 as well as the absence of foil faces on combustible insulation around windows I turn now to

02:14:47 insulation around windows I turn now to deal with some of the substantive issues

02:14:52 in these brief oral submissions I am not aiming to and in any event cannot repeat the many matters which have been covered in the vast amount of oral and documentary evidence you have received

02:15:06 documentary evidence you have received rather I want to use this opportunity to seek to bring together some of the larger themes fundamentally we would submit the question why and the so-called

02:15:18 question why and the so-called Merry-Go-Round of buck passing are two sides of the same coin a fundamentally fragmented and inadequate construction industry a dysfunctional Marketplace and

02:15:31 industry a dysfunctional Marketplace and an unfit testing and Regulatory system combined to lead inexorably to this terrible fire The Story begins with the evidence we

02:15:42 The Story begins with the evidence we heard in module one the very structure of the construction industry was one of buck passing and the buck was being passed between incompetence the cost cutting that has

02:15:54 incompetence the cost cutting that has characterized procurement in the construction industry for the last 40 years especially in the public sector was to lead inexorably to the events of

02:16:06 was to lead inexorably to the events of June 2017. indeed the evidence LED in module 1 showed that the key players in the refurbishment studio e Ryden Harley X

02:16:17 refurbishment studio e Ryden Harley X over were gracefully negligent and wholly ignorant of the fundamentals of what they were supposed to be doing their organization both individually and collectively was woefully inadequate the

02:16:31 collectively was woefully inadequate the main aim of each individual organization was to get the buck off their desk and onto someone else's as Professor torreira explained in

02:16:43 as Professor torreira explained in module 7 there was what was needed was quotes a very competent professional a professional that has some level of understanding and is interacting in an

02:16:55 understanding and is interacting in an effective manner with Professionals in other disciplines close quotes in fact there was tragic miss a tragic mismatch between a system or rather a failed

02:17:07 between a system or rather a failed system which could only operate safely if manned by highly competent well-ordered coordinated professionals and the inept ill-prepared personnel and

02:17:20 and the inept ill-prepared personnel and firms who were in fact engaged moreover those to whom the residents might expect to be the Guardians of the public interest rbkc and the TMO were

02:17:32 public interest rbkc and the TMO were equally inept in particular rbkc's building Control Officers did not know what they were doing and were in an event overwhelmed by pressures of work

02:17:43 event overwhelmed by pressures of work in a world of austerity indeed the gulf between what was required to deliver a safe building and what was provided was vast Professor torreiro explained that there

02:17:56 Professor torreiro explained that there needed to be a complete harmonization between far safety strategy and building design a feature wholly absent at grenfell

02:18:06 grenfell instead it was Apparent from the entirety of the expert evidence it used in modules one and seven that there was a Chasm between the level of competence

02:18:17 a Chasm between the level of competence required to ensure fire safety and that actually on display to take one example Professor torreiro was extremely damning about the quality of ex-over's work

02:18:29 about the quality of ex-over's work saying quotes the people who were doing those reports lacked the requisite competence to do a proper job or chose not to do a proper job close quotes

02:18:41 not to do a proper job close quotes this was sadly not only true of X over but of almost everyone associated with every aspect of the refurbishment the evidence given in module 1 was

02:18:52 the evidence given in module 1 was shocking in that it revealed a construction industry which was highly unfit for purpose and this was not an isolated situation ryzen Harley and Co were probably typical of many in the

02:19:05 were probably typical of many in the industry they just happened to get caught

02:19:09 caught but what module 2 has showed is even more horrifying the inquiry will need to condemn the actions of the manufacturers our comic celatex and

02:19:21 manufacturers our comic celatex and kingspan in the strongest possible terms they were at the very least reckless in pushing dangerous products into the market

02:19:30 market in selling those products they were fraudulent in their sales tactics and in their dealings with those who were charged with testing and certifying the products

02:19:40 products in their overarching submissions arconic seek to justify the use of ACM PE on the basis that its characteristics were well known in the industry but those

02:19:53 known in the industry but those submissions fly in the face of the contemporaneous internal evidence you'll recall Mr Vela saying internally that PE was dangerous on on facades and

02:20:05 was dangerous on on facades and everything should be transferred to FR as a matter of urgency you'll recall Deborah French of iconic sending Verla a link to a BBC

02:20:17 iconic sending Verla a link to a BBC news story reporting on afar in the UAE on an ACM facade building Miss French accepted in evidence that the dangers of PE cladding panels on

02:20:29 the dangers of PE cladding panels on high-rise buildings were well known and yet she was continuing to offer PE Corps as standard including in respect of groundwater

02:20:40 groundwater moreover our comic were at Payne's to hide the true circumstances the true facts relating to PE Villa for example

02:20:51 facts relating to PE Villa for example saying internally that this was something we have to keep as capitals very confidential for exclamation marks nor were celatex any better

02:21:04 nor were celatex any better they seek to criticize other parties to the refurbishment but they are silent as to their own role knowing as they did that RS 5000 would not meet br135

02:21:16 that RS 5000 would not meet br135 criteria on the proposed wall system and by extrapolation neither would a desktop study nor a far engineering assessment yet they were still happy to take the

02:21:29 yet they were still happy to take the sale and did so on this and many other projects

02:21:33 projects of course

02:21:34 of course The Producers should only have been selling Safe products which had been thoroughly and openly tested by reputable independent bodies and which

02:21:45 reputable independent bodies and which were then marketed to the construction industry in a transparent fashion none of this happened for example as Professor Bisby explained the way kingspan were allowed to do their

02:21:57 kingspan were allowed to do their testing quotes in order that a claim could be made that the surface of the k-15 was class zero close quotes was utterly indefensible quotes both by any

02:22:08 utterly indefensible quotes both by any manufacturer and or by any compliance testing laboratory who knowingly undertook and reported such testing indeed the manufacturers rather than

02:22:20 indeed the manufacturers rather than taking an honest and open approach was simply trying to game the system so as to place unsafe products on the market for example Professor Bisby said that

02:22:33 for example Professor Bisby said that kingspan by testing the foil facer on its own was quote just completely and utterly nonsensical and could never be defended close quotes moreover these

02:22:45 defended close quotes moreover these companies are still operating openly and unrepentantly a fact which causes particular offense to those whom we represent celotex claim to have cleaned

02:22:57 represent celotex claim to have cleaned up their act our comic do not even pretend to have done so and kingspan still assert that their products are safe on high-rise building indeed

02:23:08 safe on high-rise building indeed incredibly even after the fire kingspan have been lobbying government and others in seeking to show that cladding with European classification A2 could also

02:23:20 European classification A2 could also lead to a failed bs-8414 test this is a glaring example of the lengths to which manufacturers have gone to ensure their products continue to be

02:23:32 ensure their products continue to be marketed for example kingspan set up a test using an A2 cladding panel which they suspected would cause even a robustly designed bs-8414 test to fail they then drew that

02:23:46 bs-8414 test to fail they then drew that result to the attention of the select committee in relation to its hacket inquiry seeking to persuade them that the products used in the system tested

02:23:57 the products used in the system tested would be permitted under the government's proposals to ban combustible flooding so how could these Rogue companies operate so successfully

02:24:08 Rogue companies operate so successfully and so shamelessly well

02:24:13 the story there is that the testing and certifying bodies the bre the BBA and the labc were best to sleep at the wheel in engaging with these manufacturers and

02:24:26 in engaging with these manufacturers and at worst positively collusive with them in their sales tactics on any view they were far too close to their quotes clients close quotes and far too reluctant to bite the hand that fed them

02:24:40 reluctant to bite the hand that fed them as Professor Bisby also explained the problem was compounded because those who were charged with invigilating the likes of kingspan were in practice conniving

02:24:51 of kingspan were in practice conniving with their fraudulent conduct as he said in evidence quotes the issue is that somebody somewhere within this process of building regulation and oversight needs to be the person who stands up and

02:25:03 needs to be the person who stands up and says no this is not okay we can't be doing tests like this and that doesn't happen and that's the issue close quotes in fact the evidence given in modules 2

02:25:16 in fact the evidence given in modules 2 6 and 7 showed clearly that the so-called system of Regulation testing and certification was not in fact a system at all it was completely defective the body is charged with

02:25:29 defective the body is charged with testing and certification were unable to provide an adequate system central government was at best completely indifferent to the unfolding disaster that was the supposed system the ADB

02:25:43 that was the supposed system the ADB provided an inadequate code to regulate the industry a code which the government was unable or unwilling to reform

02:25:55 um so um

02:25:59 so um and as Professor business Bisby said quotes the system was created specifically to enable people to circumvent the rules close quotes

02:26:12 circumvent the rules close quotes in fact the actual quote system close quotes in place put a burden upon professional competency which those operating in the field were in no position to discharge

02:26:25 position to discharge this full must ultimately lie with central government for it was they alone who could devise a more appropriate regulatory framework indeed as Professor Bisby explained the

02:26:37 indeed as Professor Bisby explained the building regulations in ADB should have been much more explicit in setting out what was required of the professionals carrying out design this problem was compounded not only by

02:26:50 this problem was compounded not only by a lack of competent Personnel in the industry but also by the fact that the judgments required by the building regulations in ADB were unclear unclear

02:27:01 regulations in ADB were unclear unclear and subjective as Professor Bisby also explained

02:27:06 explained at the heart of all this was a government machine unable or unwilling to provide adequate guidance and supervision to a construction industry in desperate need of such Direction

02:27:18 in desperate need of such Direction this despite the experience of numerous serious fires as Mr Mansfield has referred to Not only was government supine but it

02:27:32 Not only was government supine but it missed the chance to make matters better when the garlic court car fire occurred instead it chose to make NASA's even worse worse further as Professor Bisby

02:27:43 worse worse further as Professor Bisby also noted if nosley had been proper and properly analyzed quotes maybe we wouldn't have had many other fires including grandfather

02:27:54 including grandfather what is striking about the British government's handling of these issues is the startling ignorance of those supposedly in charge lest it be suggested otherwise this is

02:28:05 lest it be suggested otherwise this is not a case of requiring the British government to do the impossible or to consider issues which have become clear only with hindsight on on the contrary it is apparent that

02:28:16 on on the contrary it is apparent that other jurisdictions have managed these issues much better see the Australian experience cited by Professor Torero as to what could and should have been

02:28:27 to what could and should have been achieved in Britain the inquiry will therefore have to make sweeping criticisms of the failed system of testing and regulation a quote system close quotes which has been shown to be

02:28:39 close quotes which has been shown to be totally deficient this criticism criticism should extend to the testing and certifying bodies but it should be particularly unstinting in respect of

02:28:50 particularly unstinting in respect of the governmental bodies which have allowed this disastrous situation to develop

02:28:55 develop I turn then to the way in which the tower has been inspected and maintained in the Years leading up to the fire this is a sorry story of neglect and

02:29:07 is a sorry story of neglect and indifference of which time allows two examples only the first relates to the so-called fire risk assessments carried out in the years before the fire by Carl Stokes as

02:29:20 years before the fire by Carl Stokes as to which you heard evidence in module three these were or at least should have been a crucial preventative measure both the assessment and the assessor needed to provide vital advice the basic object

02:29:33 to provide vital advice the basic object was to discern what might cause a fire how to stop it spreading and how residents could Escape in fact Mr Stokes was woefully unqualified to carry out the assessments

02:29:45 unqualified to carry out the assessments and the fras to which he put his name were repeatedly wholly inadequate nor did the TMA have any systems in place to interrogate his work or thereby to

02:29:56 interrogate his work or thereby to safeguard the interests of the residents the second example relates to the Smoke control system as to which you have heard evidence more recently this system too had a long history of

02:30:08 this system too had a long history of neglect

02:30:09 neglect non-compliance and being inoperative it is staggering that there is no evidence of any attempt to fire safety engineer any aspect of the primary refurbishment

02:30:22 any aspect of the primary refurbishment not least the SVS the smoke ventilation system

02:30:28 system the requirements for which X over omitted from its far safety strategy there was no attempt to develop an engineered fire safety design integrating other Fire Safety Systems

02:30:40 integrating other Fire Safety Systems within the building none of PSB X over or rbkc had any regard to

02:30:47 regard to bs7974 or any other fire safety design framework

02:30:53 framework the objective of any extract system as emphasized in a b ADB and the fundamental purpose of the design of any mechanical SVS for the tower was to

02:31:05 mechanical SVS for the tower was to maintain tenable conditions for means of Escape in the extended travel lobbies and for means of escape and firefighting in the single stairway in fact very

02:31:16 in the single stairway in fact very little regard was had to maintaining tenable conditions at the design stage furthermore in December 2013 rbkc rejected enlargement of the shafts

02:31:29 rbkc rejected enlargement of the shafts there was no engineering justification for this decision which did not Place safety at the heart of the project had there been competent construction management of the project Capital Works

02:31:42 management of the project Capital Works to enlarge the shafts should have been considered at an early design stage similarly had there been competent building control this fundamental early design consideration would have been

02:31:54 design consideration would have been considered consequently the SVS extra extract shaft size represented a limitation on the capacity of the system to exhaust smoke this was the first of

02:32:07 to exhaust smoke this was the first of many abject failures the design approach actually taken amounted to looking at the system as it presented itself a system which was non-operational and had not been

02:32:20 non-operational and had not been contained maintained for many years and then applying the non-woofening principles so-called to a dilapidated system

02:32:30 system PSB did not demonstrate compliance with either the regulations for the original performance requirement they ought to have aimed to produce a design that complied with one or the

02:32:43 design that complied with one or the other in the event that was not possible the system should have been condemned and a root and Branch review of performance considered therefore and in summary the design and

02:32:57 therefore and in summary the design and design delivery failed the residents in numerous important respects the design actually adopted amounted to cherry picking selected performance

02:33:09 cherry picking selected performance parameters was not a recognized industry approach and was not recommended by the relevant guidelines turning then to the Smoke control

02:33:22 turning then to the Smoke control dampers British standard en12 1018 of 2011.

02:33:29 2011. sets out the performance requirements and relevant test standard and classification standard for these dampers

02:33:40 standard for these dampers based on sections 8 and 10 of AGB 2013 the minimum performance duration of performance for the dampers protecting an Escape Route is ei20s

02:33:55 an Escape Route is ei20s a smoke control damper tested to British standard en 1366 10 of 2011 and classified to British standard en 13501 4 or

02:34:09 British standard en 13501 4 or 2007 as ei20s would satisfy the requirements of ADB 2013. however those standards were not considered at the time of the renovation project the

02:34:21 time of the renovation project the construction therefore allowed smoke to pass across different far compartments I should next and almost finally say something about water yet another area

02:34:33 something about water yet another area where the residents were badly let down in this instance by the lfb and Thames water

02:34:40 water when considering water Distribution Systems the required outcome is that the flow rate at the point of use is sufficient to meet the service requirement the advantages of testing

02:34:52 requirement the advantages of testing supply are self-evident but the lfb never did so a lack of record information and Technical knowledge combined with communication failures and

02:35:04 combined with communication failures and an absence of training precluded the efficient management of the network Thames water do not appear to have been cognizant of the substandard discharge

02:35:16 cognizant of the substandard discharge coefficients of the distribution valves and did not communicate that to the lfb of course even if the lfb had been told they would no doubt have been unaware of the significance of the fact due to a

02:35:29 the significance of the fact due to a want of familiarity with the standards furthermore Dr stoyanov rightly formed a highly critical view of the quality of

02:35:41 a highly critical view of the quality of communication between Thames water technicians and Engineers it seems there was little communication on the night of the fire and the quality of the communication did little to advance

02:35:53 communication did little to advance appropriate fire water supply to the tower when and where it was needed

02:36:00 I I turn finally to the topic of lfb testing rated Inlet pressure and flow rate there were gross failings here also

02:36:11 rate there were gross failings here also in technical competence a professor at Torero was rightly scathing about the lfb's operational response saying quotes the evidence shows that the real

02:36:23 the evidence shows that the real competency is so low that it leads to practices that endanger the public and lfb staff and prevents the organization from learning

02:36:34 from learning the evidence of Mrs Terraria Johnson and stoyanov show that the lfb has failed to engage with technical matters within their various areas of expertise Mr

02:36:46 their various areas of expertise Mr Johnson referred to poor communication as a particular issue Professor torreiro showed that the lfb were out of date and

02:36:57 showed that the lfb were out of date and one-dimensional capable only of fighting the fire they are presented with with the equipment immediately available to them

02:37:07 them in conclusion

02:37:10 and looking at this inquiry overall you are clearly going to have to make highly critical findings about a large number of people and organizations

02:37:23 of people and organizations but this is not just a story of incompetence or Worse on the part of individuals and companies they were all operating within a culture which did not

02:37:35 operating within a culture which did not encourage either competence or honesty a market and a system in which there was a headlong race to the bottom

02:37:46 headlong race to the bottom and that culture had flourished because governments and Regulators had not put in place adequate procedures to root out the fraudulent and the unskilled the

02:37:59 the fraudulent and the unskilled the fire therefore was the result of catastrophic failures on a personal corporate Regulatory and governmental scale and we urged the inquiry to so

02:38:12 scale and we urged the inquiry to so find in the strongest possible terms the bereaved survivors and residents expect the current panel to say find and they wait expectantly upon your report

02:38:25 wait expectantly upon your report they have waited patiently but the time for waiting is now over thank you very much thank you very much Mr Williamson

02:38:38 next we're going to hear a closing statement by Mr Imran Khan King's Council on behalf of another group of bereaved survivors and residents so

02:38:49 residents so uh take your time but when you're ready Mr Khan we shall look forward to hearing from you

02:39:05 good afternoon panel um when we first raised the issue of closing submissions with our clients the overwhelming view that it was going

02:39:17 the overwhelming view that it was going to be a complete waste of time uh not because they don't and they didn't think that you wouldn't produce recommendations

02:39:28 recommendations you will in the words of the advert probably produce the best recommendations in the world they thought it was complete Wasteland because they didn't think and don't think that despite your recommendations

02:39:41 think that despite your recommendations anything will change that's a concern that they have because governments in the past today's government and successive governments

02:39:53 governments there are likely to make the change that's needed the fact is that immediately after the fire

02:40:03 our clients and all those that were in grenfell

02:40:07 grenfell knew what happened and who was at fault in fact the world knew what happened and who was at fault what they wanted first and foremost what

02:40:20 what they wanted first and foremost what they expected immediately after fire was arrest prosecutions and imprisonment of those that were culpable

02:40:33 of those that were culpable but instead what they got was five years of this inquiry it's public inquiry but for all of its advantages what public inquiries do

02:40:44 what public inquiries do is they gave the appearance of change

02:40:49 without any change they give the appearance of difference without making any difference and so our clients our cohort of clients

02:41:02 and so our clients our cohort of clients weren't particularly interested in contributing to closing submissions but they were persuaded more in Hope than expectation

02:41:15 more in Hope than expectation that they should do so and they wanted us to focus on four key elements which we have done

02:41:27 and the submissions the written submissions that we have submitted I'm not going to read all of those but it's part of it and it starts with a plea from our clients A desperate impassioned plea

02:41:41 clients A desperate impassioned plea that this inquiry produces a set of recommendations and conclusions such that it leads to a wholesale change to the housing sector in the UK

02:41:52 to the housing sector in the UK our clients believe that the fire will forever be remembered we hope in the history of this country

02:42:03 in the history of this country and depending upon what you and your colleagues chair do this inquiry and its recommendations could either be recorded in that history as a forgotten footnote

02:42:15 as a forgotten footnote to the disaster or the one single moment in time which changed everything the choice is yours we have subtitled these submissions as

02:42:27 we have subtitled these submissions as quote the Magic Pencil end quote it's taken from the words of a child affected by the fire you know the family sir funnel

02:42:41 you know the family sir funnel our clients son lost his brother on the night

02:42:45 night and when asked what he would what he would want if granted three wishes he said that one of The Wishes would be for him to have a Magic Pencil said

02:42:56 for him to have a Magic Pencil said anything he'd draw he drew with it would come to life in this case he wanted the power to draw his brother back to life

02:43:08 his brother back to life in a sense this inquiry has that Magic Pencil

02:43:12 Pencil not of course to bring the deceased back to life

02:43:16 to life but to write recommendations which have the power to ensure that lives are not lost in the future not just here in the UK but elsewhere in the world

02:43:28 but elsewhere in the world as disasters like Grandville are not limited by borders and boundaries you may recall the events of Sunday 29th of August 21.

02:43:39 of August 21. the fire took hold of tower Block in Milan which had cladding identical to that on grenfold Tower in that case the absence of victims apart from two pets

02:43:52 apart from two pets was considered miraculous and down to the fact that the fire took place in the afternoon of a hot Sunday in late August when most of the residents were not at home as well as the fact

02:44:04 as well as the fact that the fire service did not even attempt to put the fire out but instead broke the doors down to get everyone out if nothing else the Milan fire shows the global nature

02:44:16 the Milan fire shows the global nature of this problem and this inquiry and the UK

02:44:20 UK and this panel can be a leader in addressing it on behalf of our clients we do not today seek to rehearse the evidence heard that would be impossible

02:44:32 would be impossible it seems to our clients know that it's self-evident to anyone who has had even a passing interest in the hearings as to what happened during the events

02:44:43 as to what happened during the events that led up to and occurred in 2017.

02:44:49 in 2017. you and your colleagues are well aware of it in any event others more skillful who've come before me have addressed you more persuasively more eloquently than I could ever do

02:45:02 our clients seek to address you in more General but equally emphatic terms in four discrete matters race and social inequality foreseeability implementation and

02:45:16 foreseeability implementation and apology

02:45:17 apology the first issue we address is out of institutional racism given the tower's history and the makeup of its residence if I was we say simply waiting to happen

02:45:29 waiting to happen we have repeatedly sir urged upon you to consider whether race and social background of the residents of town played any part in the disaster

02:45:40 of town played any part in the disaster we did that from day one in our opening submissions that plea unfortunately has fallen on deaf ears and represents a failure we say

02:45:50 say on the part of this inquiry and the missed opportunity to change the lives of Millions or people of color in this country

02:46:01 the reality is that without understanding the context in which the Tower came into being and why it was populated as it was this inquiry will have failed to understand why the disaster happened and how it can be

02:46:12 disaster happened and how it can be avoided

02:46:14 avoided the tower's Genesis is best described by the social and political theories either Dunwood who wrote this quote when grateful Tower was built in 1974 the surrounding area in Lambert Grove

02:46:25 the surrounding area in Lambert Grove was known as one of the most degraded places in London the harsh conditions of the piggeries in 19th century the slums of the 1930s and

02:46:36 19th century the slums of the 1930s and the race riots of 1958 had earned the area a notorious reputation populated by the poorest of the English working class and people of Irish Jewish and Spanish descent after 1948 and

02:46:49 and Spanish descent after 1948 and Empire Windrush Ladbroke Grove also became home to the afro-caribbean immigrants excluded from living elsewhere alongside a sizable Moroccan community

02:47:01 alongside a sizable Moroccan community grenfell quickly became known as the Moroccan Tower the result of its large number of Moroccan immigrant residents end quote

02:47:11 end quote from the outset we say the tone will set and the destiny of the residents arguably determined as Robert Booth social Affairs correspondent for the guardian noted in

02:47:23 correspondent for the guardian noted in article published in June 22. at the time of the grenfold towel refurbishment quote many councils had seized on property development some to fill holes left by

02:47:34 development some to fill holes left by government cuts others out to free market instinct to decide to boost home ownership a prime potential Redevelopment Zone in Kensington Chelsea was grenfell Tower and it's surrounding 1970s Estates

02:47:47 and it's surrounding 1970s Estates this had long been the Gentile burrowsed poorest area in 1930s the labor MPS Stafford Crips lamented of all the slums in England those North Kensington are the most

02:47:59 those North Kensington are the most tragic

02:48:01 tragic inside the council the tower was assessed as one of the borough's worst property assets a poor cousin that blights the surrounding area from a purely Financial perspective

02:48:14 from a purely Financial perspective the council viewed grenfell as worthless Laura Johnson director of housing wrote a memo to the fact that anything spent on grenfell was money down the drain

02:48:26 on grenfell was money down the drain it would seem a tower block filled mainly with so-called immigrant residents was viewed by the councilor's worthless

02:48:34 worthless social inequality in why societies unfortunately inextricably linked to socially inequality in the housing sector if you're poor and marginalized

02:48:46 if you're poor and marginalized you will be neglected if you're poor and marginalized you'll be treated differently if you're poor and marginalized you will receive less care receive less attention

02:48:57 receive less attention receive less security if you're poor and marginalized you're more likely to die we submit that this was and continues to

02:49:08 we submit that this was and continues to be indicative of the pervasive attitudes in our society towards the residents of social housing had the tragedy occurred in a different community

02:49:18 community those involved in the refurbishment would have likely taken a very different approach

02:49:23 approach as Adam Smith noted in the theory of moral sentiments this disposition to admire an almost to worship the rich and the powerful and to despise or at least to neglect

02:49:35 and to despise or at least to neglect persons of poor and mean condition don't necessary both to establish and to maintain the distinction of ranks in the order Society is the great and most universal cause of the corruption of our

02:49:47 universal cause of the corruption of our moral sentiments these words were written in 1759 some 250 years later they still regrettably apply

02:49:58 regrettably apply here

02:50:00 here it cannot and should not be the case that in 2017 the wealth social standing class or race of a person determines their future

02:50:11 their future determines whether they live or die yet that is we say precisely what happened in this case those who died in the fire were largely from low-income homes with at least 85

02:50:24 from low-income homes with at least 85 percent of them from Minority ethnic backgrounds the government's raised disparity audit in 2017 the year of the disaster so those from Minority ethnic communities

02:50:35 those from Minority ethnic communities were the most likely groups to rent rent social housing Kieran Yates writing for the guardian in 2020 notes that quote official housing

02:50:46 2020 notes that quote official housing surveys have found that 40 of high-rise residents in the social renter sector are from black Asian and minority ethnic communities which make up 14 of the population

02:50:59 which make up 14 of the population throughout the UK children from Minority ethnic communities are more likely to live in dilapidated and overcrowded housing than white people and they are 75 more likely to experience housing deprivation

02:51:12 deprivation the connection between policy and the economic reality for most people is not one that is readily recognized by those in power yates's article highlighted that quote

02:51:23 yates's article highlighted that quote the disproportionate ethnic pay Gap that communities of color experience for instance has knock-on effects lower incomes mean greater Reliance on state provision and more likelihood of ending up in low quality housing

02:51:37 ending up in low quality housing this may account for the one in six ethnic minority families in the UK who have a home with a category one hazard that is one that posed an immediate and serious risk to health and safety

02:51:50 the effect of this is therefore that Minority of the communities are disproportionately at risk from hazardous living conditions due to an unavoidable need to rely on

02:52:01 due to an unavoidable need to rely on social housing as such

02:52:05 as such Not only was race crucially relevant to the disaster in the context of social housing

02:52:11 housing but also to the attitudes of those engaged in fighting the fire and those providing relief to the survivors

02:52:22 we told you previously so of a comet made

02:52:26 made in an article in March 2021 the head of the London fire brigade Andrew Rowe he told the guardian that quote culture of casual racism and misogyny remains so

02:52:37 of casual racism and misogyny remains so prevalent within pockets of the organization that he feared his mixed Heritage daughter might not be treated with dignity and respect at some fire stations

02:52:47 stations the Westway trusts the charity involved with assisting residents in the aftermath of disaster said it accepted the fines of review by the tutu foundation in 2020 that charity has been

02:52:58 foundation in 2020 that charity has been and remains institutionally races the foundation's report further found that quote the grunt of fire brought into the wider public domain the long-held accusations by local community that the

02:53:09 that the rbkc had failed to listen to their repeated concerns which they believed was a result of institutional racism historic disenfranchisement marginalization and inequality

02:53:22 marginalization and inequality our clients find it astonishing sir astonishing but given the history of the Tower you the panel have persistently refused to consider this vital issue

02:53:34 to consider this vital issue our clients implore you appeal to you that you still have both time and opportunity to rectify this failure by applying Sir William McPherson's definition of institutional racing

02:53:47 definition of institutional racing referred to earlier is not to point a finger at any one individual at their races the definition is clear and it's worth repeating

02:53:58 repeating quote the collective failure of an organization to provide an appropriate and Professional Service to people because of their color culture or ethnic origin

02:54:08 origin it can be seen or detected in processes attitudes and behavior that amount to discrimination through prejudice ignorance thoughtlessness and racist stereotyping which disadvantaged

02:54:19 stereotyping which disadvantaged minority ethnic people in applying this definition to the conduct of those organizations involved our clients ask you to find that institutional racism infected every

02:54:31 institutional racism infected every aspect of the disaster from who was placed in the tower to how they were treated during and after the fire

02:54:41 fire the sad unavoidable truth is that race and contribute to the loss of 72 lives our clients urge you to make this finding nothing less than this will do

02:54:55 finding nothing less than this will do the second issue we address is foreseeability we submit that the disaster was not only foreseeable but foreseen by the many public and private sector institutions and individuals involved

02:55:08 individuals involved as this inquiries heard cladding fires of this nature are not a new occurrence Mr Mansfield Casey already referred to Summerland fine Knights of three on the Isle of Man

02:55:19 Isle of Man 50 people died and a further 80 was seriously injured there has been recommendation of to recommendation there's been nosley Heights in Liverpool in 91 Garner Court in Scotland in 99

02:55:32 in 91 Garner Court in Scotland in 99 Harrow Court in stevenage Hertfordshire in 2005.

02:55:36 in 2005. and local house in London in 2009.

02:55:43 since Summerland and the multitude of fires in between that date and grenfold the position is best summed up by MP Harrod Harman speaking in relation to the fire at Lackland house and she said

02:55:54 the fire at Lackland house and she said this quote whatever all of us did it wasn't enough because if you've got something that happened and six people died and then exactly the same happens again and even more people died than none of us did

02:56:06 more people died than none of us did enough

02:56:08 enough whether it's me as a local MP or whether it was a ministers or people heading up the fire brigade none of us did enough

02:56:19 our clients ask that you make a finding perhaps the easiest of the finders that you can make that the fire on the 14th of June was both foreseeable and foreseen by those involved in this refurbishment with greed in the form of

02:56:30 refurbishment with greed in the form of cost-cutting profit being the key motivator

02:56:34 motivator leading to at one point we asked we indicated at least 15 readily identified opportunities where components the cloud and use on the tower could and should have been identified as unseen

02:56:47 identified as unseen all of the correspondence and information gathered for this inquiry demonstrate that cost cutting profit greed was prioritized at the expense of the quality of the work and far above

02:56:59 the quality of the work and far above any consideration of our client's safety and the importance of their lives as is commonplace in the private sector there existed quote a callous indifference to anything morality

02:57:11 indifference to anything morality honesty Life Safety that was not related to the bottom line of the business it's meant that Corners were cut avoidable errors were made at every

02:57:22 avoidable errors were made at every single stage of the works from conception all the way through to completion the fact is that this should not have happened

02:57:31 happened in the wealthiest Borough in the country

02:57:36 long chains of subcontracting gave everyone involved a false sense of security that even if they made mistakes others in the chain could compensate for their shortcomings

02:57:48 their shortcomings perhaps the most troubling aspect was that for many of those working in those long complex chains of subcontracting a question of whether they were at fault was not even considered

02:58:00 was not even considered as Robert Booth again noted in the 2022 article quote the sociologist Sigmund Bauman once wrote that violence in our age is defined by distance

02:58:12 defined by distance summarizing Bauman's idea the journalist Daniel trilik has written that this means not only physical distance but the social and psychological distance produced by complex systems in

02:58:23 distance produced by complex systems in which it seems everybody and nobody is complicit

02:58:27 complicit the buck passing we've heard about from Mr Williamson King's Council this Theory May provide at least some explanation of why such a large number of individuals and institutions made a

02:58:40 of individuals and institutions made a slew of fatal errors despite being fully aware of the dangerousness of their decisions

02:58:46 decisions as Booth noted this is the reason why until we change the way our society is organized it might happen again

02:58:57 it might happen again and our clients say it's not a question of

02:59:00 of whether a fire like grenfell might happen again is for them a question of when it will happen

02:59:08 happen and it's only if we change the way our society is organized can we possibly have any chance of such a disaster not happening again and for that to happen our clients

02:59:21 and for that to happen our clients seek recommendations in relation to increased State regulation of the Housing Industry because as you're aware consecutive governments particularly from the latter half of the 20th century

02:59:32 from the latter half of the 20th century onwards

02:59:33 onwards have pledged to cut red tape reduce regulation on industry and free companies

02:59:39 companies the recent history of building regulations shows that the flagrant disregard of the health and safety of residents has been institutionalized it has produced a culture which

02:59:50 it has produced a culture which engenders a race to the bottom caused by ignorance indifference and because they do not facilitate good practice

03:00:01 accordingly it's vital for recommendations to be made such the state properly regulates the construction industry to ensure that homes do not become flammable death traps

03:00:12 traps rather than to leave this matter to the mercy of the markets which has been the case until now

03:00:20 the third matter discrete matter our clients seek to address you on through me is in terms of implementation of the recommendations

03:00:31 recommendations Miss Manfield King's Council has already addressed you on some parts of it the starting point in our submission is from the case of RV Secretary of

03:00:43 is from the case of RV Secretary of State for the home Department ex-party I'm in

03:00:46 I'm in uh when Lord Bingham spoke of the purpose of holding an inquiry into death in that case of zahid Mubarak who was murdered in his cell at Felton in March 2000.

03:00:57 2000. Lord Bingham says in that case an Inquirer was required quote to ensure so far as possible that the full facts are brought to light that culpable and discredible conduct is

03:01:08 that culpable and discredible conduct is exposed and brought to public notice that suspicion of deliberate wrongdoing if unjustified so late the dangerous practices and procedures are rectified and that those who have lost their loved

03:01:19 and that those who have lost their loved ones

03:01:20 ones May at least have the satisfaction of knowing that lessons learned from his death May some may save the lives of others

03:01:27 others now those were pressure words uttered in 2003. in the context of this inquiry our clients suggest that culpable and

03:01:38 our clients suggest that culpable and discretible conduct has been plainly and uncontrovertibly exposed and there's not just been suspicion of deliberate wrongdoing but actual evidence of the same

03:01:50 evidence of the same what then remains now well it's the making the fine making the findings official and making recommendations which Ensure

03:02:01 recommendations which Ensure that the dangerous practices and procedures which have clearly been identified during the course of inquiry are rectified for the future and then will they those who've lost

03:02:12 and then will they those who've lost loved ones and those who've suffered in other ways will have the satisfaction doing that Lessons Learned From the disaster May save the lives of others that members of the panel is a heavy burden that you and your colleagues bear

03:02:24 burden that you and your colleagues bear and are required to discharge

03:02:29 you may be aware of a report published in December 2017 by The Institute of government which found that over the years the inquiry has become the gold standard when it comes to Independent

03:02:42 standard when it comes to Independent investigations of design such as grenfell we have three or four huddling as we speak one here only a few weeks ago

03:02:51 the report identified that

03:02:56 638.9 million has been spent by Central default governments more than 68 public inquiries since 1990. in late 2010 there were as many as 15

03:03:07 in late 2010 there were as many as 15 inquiries taking place at the same time however despite becoming the choice method of independent investigation their efficiency has been inadequate

03:03:18 their efficiency has been inadequate since 1990 has taken average of two and a half years for reports to reproduce and for at least nine inquiries have taken five years or more we're in that category

03:03:29 category within the 60 inquiry reports received by the UK and devolved governments between 1990 and 2017. there were at least

03:03:37 least 2625 recommendations for change of the six to eight inquiries that have taken place since 1990 only six only six have received a follow-up by a select

03:03:49 have received a follow-up by a select committee to ensure that government has acted

03:03:53 acted what the report found was that overall the formal checks and procedures we have in place to ensure that public inquired leads change are inadequate there's no routine procedure for holding government to account for promises made

03:04:05 government to account for promises made in the aftermath of inquiries the implementation of recommendation is patchy in some cases repeat incidents have occurred and there's no system for allowing cries to build on the learning

03:04:16 allowing cries to build on the learning of their predecessors

03:04:19 how much money has been spent on this inquiry

03:04:24 inquiry and how do we ensure that that money is well spent so that there is real change for the future

03:04:31 future the report states that even in case where government decides not to implement change a process of government being called to explain its decisions is appropriate not least that members of the public

03:04:43 not least that members of the public have been directly involved in inquiry understand why change has not been taken forward

03:04:50 we've already listed a number of fatal fires which preceded we in our written submissions referred to them earlier the most disturbing aspect of these

03:05:02 the most disturbing aspect of these incidents is perhaps a lack of meaningful action by responsible institutions to prevent future loss of life

03:05:10 life it appears that those in power simply dither and dawdle waiting for these events to dissolve from public consciousness who remembers Summerland in 1973 for example

03:05:22 example so they those in power can evade taking any remedial action to prevent future disasters

03:05:30 some land 73 knowsley Heights Garnet Court Harrow Court lacknell House [Applause] so our clients ask

03:05:42 so our clients ask given that these events have happened time and time again and recommendations made time and time again and legislation changed time and time again what could you what could this inquiry

03:05:54 what could you what could this inquiry do

03:05:55 do which which previous inquiries have not been able to the reality is that whilst recommendations from the inquiry will go it is hopes some way to making buildings

03:06:07 it is hopes some way to making buildings more secure the fact is that if property remains a valuable commodity and is treated as a means to make a profit Corners will still be cut and the

03:06:18 Corners will still be cut and the dangers that exist today will still be the dangers that exist tomorrow and the dangers that exist in the future lives will be lost unless change occurs

03:06:30 lives will be lost unless change occurs and we're not asking the kind of change which is no more than at best second order change that is an adjustment of policy and practice

03:06:41 practice wholesale change a change the overall paradigm not a tinkering of it now whilst chair panel members you may feel it unease at addressing what might

03:06:53 feel it unease at addressing what might be seen as a political part of the process now clients have come to the inexorable conclusion that it's only when social inequality is entirely removed from the housing sector

03:07:05 entirely removed from the housing sector convey and their children truly sleep safely in their beds and the amount of for you and your colleagues showing how much in what way your recommendations can deal with this

03:07:17 your recommendations can deal with this issue

03:07:20 whatever your recommendations are we have grave concerns that this government in particular and successive governments in the future of whatever persuasion will Implement what you recommend

03:07:34 will Implement what you recommend so

03:07:36 so to ensure public choirs can lead to real change we refer again to the 2017 Institute of government report which referred to a need to have some or some form monitoring mechanism

03:07:49 some form monitoring mechanism you've had some suggestions from this mountain KC we propose and ask that you take up what inquests have recommended a setting

03:08:01 what inquests have recommended a setting up of a national oversight mechanism and to go on from what Mr mantle said about the Lawrence recommendations and the committee that was set up which was attended by Mr Mrs Lawrence

03:08:14 which was attended by Mr Mrs Lawrence the labor government soon disbanded it forgotten about

03:08:20 and it's one of those scenarios where everyone assumed after the Lawrence and MacPherson recommendations that were now dealt with the issue of race we have a report we have recommendations

03:08:31 we have a report we have recommendations that's done and dusted that is not what we want to happen in this case

03:08:39 a national oversight mechanism to examine regular progress on the state of implementation of recommendations inquiry

03:08:46 inquiry an inquest inquest campaign to sub recession mechanism says this is to quote ensure that recommendations rising from inquiries inquest and investigations into avoidable deaths are

03:08:57 investigations into avoidable deaths are implemented this would mean that once recommendations are made an independent body would Monitor and hold State and public bodies accountable for their decisions and response recommendations

03:09:09 not only this but our view is it should go further it's not we say it's simply a question of

03:09:17 of asking and giving 28 days to find out when whether recommendations have been made or what progress is made but to punish and have punitive measures for those who don't comply

03:09:28 for those who don't comply with those obligations those responsibilities is to ensure that organizations are not allowed to continue their egregious evasion of responsibility our clients truly

03:09:40 our clients truly truly hope that this inquire does not prove to be yet another administrative formality or box ticking exercise

03:09:52 sure at Summerland 50 died

03:09:57 50 died a Garner Court one died at Harrow Court three died at lachana house six died at grenfell Tower 72 die

03:10:10 as it stands not a question of if but merely when and where the next fire will occur and how many will die

03:10:18 will die our clients hopes hope is that when this inquiry concludes they and their families can be confident that your recommendations constitute a genuine attempt to put an end to this fatal line of History

03:10:33 moving on much has been said by the lawyers for the core participants who are not bereaved survivors or registers including what might have been intended

03:10:47 including what might have been intended as an apology for the acts and Mission and failures and whilst I haven't seen what would be in their closing remarks

03:10:58 it seems to our clients that what is now required from each of them is an unequivocal unambiguous and forthright apology for their part in the disaster

03:11:10 apology for their part in the disaster and we look forward to those apologies when each of the lawyers

03:11:16 lawyers makes their closing submissions as William McPherson rightly said unless there is recognition from those who failed recognition acknowledgment and acceptance of the problem

03:11:28 acceptance of the problem it cannot be solved we look forward to it saying each and every League representative on behalf of these clients to make that apology during their closing remarks

03:11:41 apology during their closing remarks and in the event that any does not our clients will consider this to be Injustice heaped upon Injustice and a mark of disrespect

03:11:51 finally sir we have been specifically asked to repeat that which was said at the fifth Memorial commemoration at Westminster Hall

03:12:00 Hall because it Bears repeating we sat out a part of what was said which we have rephrased for today

03:12:13 after this inquiry has finished and reported

03:12:16 reported you each of us all of us

03:12:20 all of us will go back to our homes and offices and back to our work whilst our clients will go back to empty houses

03:12:29 houses not homes

03:12:31 not homes their actual homes were destroyed in the fire houses that are missing family photographs and heirlooms we all of us will see our family and loved ones

03:12:42 loved ones the bereave will be haunted by the memory of theirs no longer will they be able to embrace their family members tuck their children into bed read them a bedtime story or have a family meal around the dinner

03:12:53 have a family meal around the dinner table

03:12:55 table every morning they will have to wake up to an empty bed and aching heart know that they won't be taking their child to school or teach them how to ride a bike swim

03:13:06 swim no longer will they attend parents evening or see the smile on their children's faces when they pass their first exams or driving tests no longer will they see their child graduate from University or get married

03:13:17 graduate from University or get married and they will be haunted daily with the guilt of what more they could or should have done to save the life of their loved one

03:13:27 no parent should outlive their child no parent should be deprived of the joy and wonder of seeing the child grow up and care for them and they themselves get old

03:13:38 get old this all of this has been lost to so many people and all because of fire that could and should have been avoided and if this was not enough our clients

03:13:49 and if this was not enough our clients have had to suffer the indignity and pain of having to fight for justice within this inquiry with the Metropolitan Police and with those who were legally responsible and what does this Justice look like

03:14:02 and what does this Justice look like our clients are clear if nothing changes their loved ones would have died in vain and they're not prepared to accept that they want wholesale change the housing sector in this country so they're so

03:14:14 sector in this country so they're so there is safe and suitable housing for all

03:14:18 all not just the white able-bodied and wealthy

03:14:22 wealthy they want meaningful recommendations to come from this inquiring they want those recommendations implemented in full and in a timely manner they want the law to change that those who are considered

03:14:33 change that those who are considered criminally cultural are swiftly prosecuted and properly punished they want those who are responsible for failures to be forced to accept responsibility of the outset rather than

03:14:44 responsibility of the outset rather than playing the blame game as almost every party has done during the inquiry and when tragedies such as this occur and they will when everyone knows what happened and

03:14:56 when everyone knows what happened and why it happened and who was at fault they didn't want the victims to have to wait for half a decade as I've had to do here

03:15:02 here they also want the 14th of June to become a national day to memorialize a grenful tower fire so is there lasting and permanent Legacy of something that is never forgotten

03:15:13 of something that is never forgotten so that it cannot be forgotten so our last plea on behalf of our clients power is for you to recommend the 40th of June a national day of remembrance

03:15:25 national day of remembrance So This Disaster this tragedy and those that suffered so much are never ever forgotten thank you thank you very much

03:15:38 well it's five minutes to one I think that's a good point of which we break for the morning we'll resume please at two o'clock thank you very much