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

Full transcript

00:22:16 foreign

00:22:23 now the next statement is going to be made by Mr Martin seaward on behalf of the fire brigades Union Yes

00:22:35 good afternoon sir members of the panel and assessors

00:22:41 I intend to address six topics this afternoon

00:22:44 afternoon the contribution made by deregulation to the disaster the complacency of the refurbishers Water Supplies the response of the lfb the fire control switch and the smoke

00:22:56 the fire control switch and the smoke control system I would like to start by acknowledging the hard work of the fbu officials especially Gareth Beaton and Steve White who've supported the the effort on behalf of this inquiry

00:23:09 the the effort on behalf of this inquiry from the beginning um and the legal team representing the fbu that's Gerard Steelyard and Harry Thompson of Thompson's Nick Toms and Lord hendy Casey of council

00:23:20 Lord hendy Casey of council there are others of course but I particularly wanted to thank thank these starting with deregulation the disaster was a direct consequence of a generation of government policies which combined to

00:23:33 of government policies which combined to create a death trap for the residents of grenfell Tower the private sector companies involved in the refurbishment bear heavy responsibility however it would be wholly wrong and provide no justice to

00:23:44 wholly wrong and provide no justice to victims to leave the blame there they were encouraged to act as they did by 40 Years of political decisions in the service of an ideology based on the

00:23:55 the service of an ideology based on the prioritization of commercial interests and profit Above All Else including Public Safety deregulation encompasses privatization and cuts to Public Services as well as

00:24:06 and cuts to Public Services as well as statutory deregulation replacing prescriptive rules with functional requirements it's part of the ideology of neoliberalism which prioritizes Above All Else The Liberation of

00:24:18 All Else The Liberation of entrepreneurial freedoms and private business interests through a largely unfettered free market the role of the state is limited to creating and maintaining an Institutional framework to support the

00:24:30 Institutional framework to support the free market commercial interests and profits have thus been prioritized over and above the needs of citizens even in relation to fire safety there were as you've heard no life

00:24:42 there were as you've heard no life safety exceptions to protect citizens from harm by fire deregulation serves the interests of a social system based on profit and greed has led to gross inequality in society

00:24:53 has led to gross inequality in society and has failed the vast mass of the UK's population including the residents of grimfield Tower culture

00:25:01 culture sorry the culture of health and safety has been deliberately and irresponsibly undermined by ministers pursuing their deregulatory agenda regulations have been repeatedly depicted as pointless

00:25:12 been repeatedly depicted as pointless time wasting administrative bureaucracy that impedes private Enterprise deregulated legislation has not been effectively enforced neither the fire and rescue Service Act 2004 the fire

00:25:25 and rescue Service Act 2004 the fire safety order 2005 Northern building regulations 1985. effective enforcement seen as another burden on business has instead been progressively weakened by

00:25:36 instead been progressively weakened by successive governments since 1985 with even with ever greater ambiguities and loopholes being introduced with confusing Guidance with part privatization of regulatory bodies and cuts to enforcing authorities this has

00:25:49 cuts to enforcing authorities this has allowed the construction industry to effectively ignore fire safety by way of example the number of rbkc's areas surveyors was halved from 12 to 5

00:26:00 areas surveyors was halved from 12 to 5 prior to the fire in the four years before the fire their building Control Department lost 10 surveyors with between them 230 years of experience and gained just one graduate replacement

00:26:12 gained just one graduate replacement the agenda of deregulation as pursued by successive governments is thus inimical to Human Rights health and safety and equality

00:26:22 equality the anti-health and safety Culture engendered by deregulation informed the approach of all the private sector companies involved in the refurbishment of grenfell Tower encouraged by government and not deterred by

00:26:34 government and not deterred by enforcement authorities they focus solely on getting the work done as quickly cheaply and for them as profitably as possible this widespread culture of complacency

00:26:45 this widespread culture of complacency materially contributed to the prevalence of worrying standards adopting Dr Lane's phrase from module 7 and so also to the failure of anyone involved in the grenfell tower refurbishment to think

00:26:57 grenfell tower refurbishment to think fire

00:26:58 fire we ask GTI to find the promotion of this culture was a consequence of the deregulation policies pursued by successive governments and a significant factor leading to the grenfell tower

00:27:09 factor leading to the grenfell tower disaster

00:27:10 disaster the fbu believes these policies tragically came together on the 14th of June 2017 to create the worst residential fire since World War II it informed government policy since 1979

00:27:22 it informed government policy since 1979 and has remained the Mantra of the current government despite grenfell until at least the 22nd of October 22 with Downing Street inundated with advisors recruit

00:27:33 inundated with advisors recruit recruited from neoliberal think tanks the brexit freedoms bill for example is now intended to remove all regulations derived from EU law on 31st of December

00:27:44 derived from EU law on 31st of December 2023 unless the government determines particular Provisions should be kept this further threatens Public Safety and workers rights

00:27:54 deregulation has been has become synonymous with central government abandoning responsibility for large areas of our society including building regulations building control testing and certification foreign Rescue

00:28:07 testing and certification foreign Rescue Services and fire safety we look at each of these areas in turn starting with building regulatory regime statutory deregulation significantly weakens the protection provided by the building

00:28:18 protection provided by the building regulations their dramatic and fundamental Revision in 1985 saw detailed technical Provisions replaced by functional requirements without any resources to achieve the competency required to meet

00:28:30 achieve the competency required to meet them or to enforce them and without clear and updated National guidance in ADB you're familiar of course with Dame Judith Hackett finding that the the regime was not fit

00:28:43 finding that the the regime was not fit for purpose and left room for those who want to to take shortcuts we agree and ask the panel to find the same

00:28:51 same the department of leveling up now admits as much in paragraph 5f of its overarching statement this was Central government's abandonment of responsibility in the

00:29:02 abandonment of responsibility in the wake of deregulation likewise building control has been a story of part privatization and deregulation since 1984 local Authority building control has been forced to compete with

00:29:13 control has been forced to compete with private sector approved inspectors as an alternative to and in competition with local Authority building control bodies who have had to cover their costs by

00:29:24 who have had to cover their costs by selling their services to the very developers they were supposed to control the fear of losing work and income introduced a conflict of interest and deter them deterred them from a rigorous approach to their enforcement duties

00:29:36 approach to their enforcement duties public expenditure Cuts also undermined them

00:29:40 them thus a further important protection for Public Safety had been eroded by deregulation we've seen for example how the local Authority building control served the interests of kingspan not of the public

00:29:52 interests of kingspan not of the public by wrongly certifying k-15 as a product of limited combustibility the building research establishment is another story of cuts and privatization since 1987 the bre was made to work

00:30:04 since 1987 the bre was made to work closely with the construction industry in the run-up to its privatization and to be citing Nicholas Ridley in in the House of Commons 1987 more concerned than at present with fostering

00:30:16 than at present with fostering competitiveness and less with performance standards on the 2nd of April 1990 the bre was turned into an executive agency of government in order to help extend its ability to compete for commissions from

00:30:29 ability to compete for commissions from both the public and private sectors Staffing was halved from 1 350 in 1975 to just 654 in 1989. privatization in 1997 brought with its

00:30:43 privatization in 1997 brought with its significant conflicts of interest that impacted on bre's ability to protect the public it was no longer rigorous and independent but instead at increasingly close links with the

00:30:54 increasingly close links with the construction industry that of course was the purpose of its privatization in breach of its charitable objective the privatized bre failed to warn the public or the building sector of the unique

00:31:06 or the building sector of the unique hazards associated with the use of acmpe on the exterior facade of a high rise likewise the British Board of Edgar Mall always in the public in the private sector always with extensive links with

00:31:19 sector always with extensive links with construction industry with its board members representing the construction and cladding industry on which the BBA depended for income the BBA could not explain the false or

00:31:30 the BBA could not explain the false or misleading entries on the kingspan certificate which served the interest of the sponsor not the public at best they actually in a way which was to quote Council to inquiry Supine and lead and footed turning to the

00:31:42 lead and footed turning to the deregulated foreign rescue service deregulation led to the passing of the far and Rescue Services act 2004 which directly weakened the ability of the fire and rescue service to do its job

00:31:55 fire and rescue service to do its job by the fire and Rescue Services act central government abandoned its responsibility so it abolished the central fire brigades advisory Council cfbac this was the one body that had it

00:32:07 cfbac this was the one body that had it remained in existence could reasonably have been expected to have developed operational guidance in relation to high-rise buildings including cladding risks and stay put

00:32:18 including cladding risks and stay put which abolition limited the fire and rescue service's ability to learn lessons from crowding fires and or to address and resolve recurring issues such as poor Communications and the provision and use of water when fighting

00:32:30 provision and use of water when fighting far in high-rise Residential Building secondly the ACT forced Reliance solely on Chief officers bodies the Chief Fire Officers Association see Farrer

00:32:41 Officers Association see Farrer and their successor the National Fire Chiefs Council nfcc these Chief Fire officers were the only advisors to ministers and were given responsibility for operational guidance

00:32:52 for operational guidance the fbu was sidelined rather than resist deregulation the cfoa and the nfcc facilitated it rather than resist austerity Cuts Chief

00:33:04 rather than resist austerity Cuts Chief officers implemented them deregulation even deterred leaders of the lfb from raising issues of simplifying or clarifying fire safety legislation as they feared it would lead

00:33:15 legislation as they feared it would lead to more deregulation based on the government's one in two out policy as Ron Dobson told the panel on day 211

00:33:25 day 211 the fbu is disappointed that the inquiry hasn't put cfoa and nfcc representatives on the witness stands during its proceedings with the exception of Mr mcgurk who was of course given the

00:33:37 mcgurk who was of course given the protected status of an objective witness rather than someone who had played a key role in creating many of the problems identified within the foreign rescue service

00:33:46 service thirdly the foreign Rescue Services act removed the requirement for cuts to a brigade's establishment to be approved by a minister Chief Fire officers and fire authorities

00:33:57 Chief Fire officers and fire authorities including London under the control of Boris Johnson as mayor could thus cut the establishment I.E staff stations equipment without constraint and they did

00:34:08 constraint and they did further the foreign Rescue Services act also removed national standards of Fire cover this meant that the same fire in the same type of building could attract a different attendance in different parts of the country

00:34:20 parts of the country in London this led to cuts to the number of firefighters fire stations and appliances and to the predetermined attendancies and it cuts in the control room and the

00:34:31 and it cuts in the control room and the fire safety department all of which directly impacted on the grenfell tower disaster

00:34:37 disaster at the same time the government abolished Her Majesty's inspectorate of fire services hmifs

00:34:45 and that led to the loss of oversight of local fire brigades thus central government delegated all responsibility for the provision of Fire and Rescue Services to 47 now 45 a local

00:34:58 and Rescue Services to 47 now 45 a local brigades government's abandonment of responsibility is evidenced by the dearth of guidance issued to local brigades under section 21 of the act or otherwise even regarding recommendations

00:35:09 otherwise even regarding recommendations made by proper Authority following investigations into disasters preceding Grim film

00:35:14 Grim film it's evidenced by the petering out of the national framework for integrated risk management planning a process by which local brigades are supposed to assess the risks in the area and budget for the resources needed to

00:35:26 and budget for the resources needed to cover them instead in the vacuous National framework the irmp process rapidly became a tool to implicate it to implement phased Cuts instead of an intelligent assessment of

00:35:38 instead of an intelligent assessment of what was needed deregulation also led to privatization in the foreign rescue service privatization of training damaged the ability of the lfb to respond to

00:35:50 ability of the lfb to respond to training needs the ongoing threat of privatization meant that control was prohibited from recruiting despite the numbers of control room staff being below the minimum required which in turn impeded

00:36:02 minimum required which in turn impeded training

00:36:03 training the regulatory reform fire safety order of 2005 replaced the certification and enforcement regime of the five precautions act 1971 with a far looser self-compliance system

00:36:15 self-compliance system fire risk assessments became the responsibility of a responsible person usually the landlord who would employ third-party fire risk Assessors for conflicts or high risk premises they

00:36:26 conflicts or high risk premises they were not required to have any competency or professional qualifications its purpose was deregulatory the office of Deputy Prime Minister clarified its deregulatory purpose in a statement

00:36:37 deregulatory purpose in a statement issued on the 19th of April 2004 the aim of the proposed reform that is the regulatory reform fire safety order is to reduce burdens on business

00:36:49 is to reduce burdens on business in grenfield Tower RB Casey's and the tmo's fire risk management systems established under the new fire safety order were under-resourced and unfit for purpose it led to the appointment of

00:37:00 purpose it led to the appointment of Karl Stokes who was neither qualified nor competent to risk assess a complex building like grenfell Tower he was appointed after submitting the lowest tender He was largely unsupervised Brendan Lewis accepted before this panel

00:37:13 Brendan Lewis accepted before this panel that the government failed to address concerns about the competence of unqualified fire risk assessors because of its presumption against regulation so Mr Stokes remained in his role

00:37:25 so Mr Stokes remained in his role and a further layer of protection for the residents of grenfell tower was thus Stripped Away as a direct consequence of central government policy this led to the failure to risk assess the rain

00:37:36 the failure to risk assess the rain screen cladding system or the vastly increased need for Effective compartmentation or the lack of fire safety measures in grenfell Tower without any evacuation plan not even for

00:37:47 without any evacuation plan not even for those who needed help to evacuate no firefighting lift no working fire control switch with a triangular key no smoke control system protecting the lobbies no wit Rising Main and many flat

00:37:59 lobbies no wit Rising Main and many flat entrance doors not adequately resisting fire or self-closing

00:38:05 deregulation impacts his central government itself and led the dclg into breach of Article 2 of the European convention on human rights the right to life

00:38:14 life Lord pickles could not explain why he and his Department failed to address concerns about ambiguities and approved document B the need to withdraw class zero and the prevalence of acmpe despite

00:38:27 zero and the prevalence of acmpe despite the best efforts of the local house coroner and the all-party Parliamentary fire safety and rescue group who repeatedly raised the issue between 2014 and 2017.

00:38:37 and 2017. instead he and his Department deliberately downplayed the risk of rapid fire spread associated with combustible cladding systems thereby contributing to the widespread misunderstanding of the dangers of using

00:38:48 misunderstanding of the dangers of using combustible cladding on high rise nor could you explain why contrary to his self-serving and untrue evidence the building regulations and approved document B were not exempt from the

00:39:00 document B were not exempt from the deregulation policy the explanation Lies We submit in the government's continuing adherence to the deregulatory agenda which stifled its ability to protect society as Mr lidsom

00:39:12 ability to protect society as Mr lidsom told the panel on day 241 the fact that there may be societal benefits as a consequence of the regulation was not something that was taken account of in one in one out terms it was the net

00:39:24 one in one out terms it was the net annual equivalent cost of business which was the key metric the government would not Fetter the ability of manufacturers of trading and insulation to Market their products with impunity instead the government ignored

00:39:37 impunity instead the government ignored and suppressed evidence that cast doubt on its policy as revealed by the request to play Down the issue of the fire following nosley Heights as revealed in the departmental memorandum Unearthed by

00:39:50 the departmental memorandum Unearthed by Professor Bisby

00:39:53 and it failed to introduce or adopt EU standards even prior to brexit and far from correction and confusion in approved document B they added ambiguity by extending the routes to compliance to

00:40:06 by extending the routes to compliance to include desktop studies deregulation directly led to the reduction in staff in the civil service including in the dclg and so reduced its Effectiveness in addressing these issues

00:40:17 Effectiveness in addressing these issues the head count in the building regulations Section of the tclg reduced by 40 percent in 2006 there were 14 construction Professionals in a division with a much smaller scope with three grade sixes

00:40:29 smaller scope with three grade sixes supporting the deputy director by 2015 this had reduced to five technical Specialists with one grade six that was Mr Martin who lamented to the panel his lack of

00:40:41 who lamented to the panel his lack of peer review which contributed to his failure to confront ministers with the need to resolve ambiguities in the ADB these staff reductions reflect Central government's abandonment of

00:40:52 government's abandonment of responsibility deregulation also damaged social housing the decay in neglect of social housing by central government and the local Authority one of the richest in the UK

00:41:03 Authority one of the richest in the UK did not just mean that the occupants of Greenfield Tower had poor quality homes it cost we say 72 of them their lives since 1979 publicly owned social housing

00:41:14 since 1979 publicly owned social housing has been subject to part privatization and neglect part privatization was achieved through the introduction of management companies such as the TMO and the right to my policy we saw the sale

00:41:26 the right to my policy we saw the sale of large amounts of council housing much of which has ended up in the ownership of private sector landlords unsold properties have been starved of funds

00:41:35 funds grenful Tower was no different as the evidence in Phase 2 demonstrated prior to refurbishment the block was in a bad state of repair it was described as one of the tmo's worst property assets it

00:41:46 of the tmo's worst property assets it was refurbished due insignificant part to being considered an eyesore next to a brand new school academy building its disrepair was then hidden beneath the cladding

00:41:57 the cladding not surprisingly given the funding climate and social housing the main driver of the refurbishment was cost ahead of quality and programming the desire to keep costs down pervaded nearly all the really important

00:42:09 nearly all the really important decisions made in the refurbishment including the initial choices of architect

00:42:14 architect fire consultant and design and build contractor the use of acmp creating panels in preference to zinc metal ones and the amount of work done by Studio e and X over particularly after Ryden

00:42:26 and X over particularly after Ryden became the design and build contractor Griffith Tower was a disaster waiting to happen in consequence of all these policies introduced pursuant to successive governments deregulatory

00:42:38 successive governments deregulatory agenda coming together to create an unparalleled housing disaster the policies were ruthlessly exploited by private sector companies taking advantage of changes they had sought through sponsorship and party funding

00:42:50 through sponsorship and party funding donations the fbu believes the real Comforts of the disaster are those in power at the top I.E ministers following their deregulatory agenda to the detriment of fire safety and the

00:43:02 detriment of fire safety and the directors of Industry on which they depended for sponsorship and party funding

00:43:09 funding turning now briefly to the complacency of those in the refurbishment the key players empty demonstrate the widespread disregard of fast safety the failure to think fire

00:43:21 failure to think fire starting with rbkc and the TMO they bear a heavy responsibility principally for the flawed appointments of Studio e x over and Ryden for prioritizing value over quality at the expense of Life

00:43:32 over quality at the expense of Life Safety

00:43:33 Safety for the widespread failures of their fire risk management systems for not planning for the evacuation of their residents especially those unable to evacuate unaided for not upgrading to a firefighting lift with a triangular key

00:43:45 firefighting lift with a triangular key to operate the fire control switch for the failings of building control and for the failing to engage effectively or meaningfully with the residents of grenfell Tower the cladding manufacturers including

00:43:57 the cladding manufacturers including iconic kingspan and celetics failed to disclose material test results or to correct glaring errors in marketing literature they dishonestly fabricated test Rigs and manipulated the

00:44:08 fabricated test Rigs and manipulated the testing of certification system they treated testing bodies such as the bre and certification bodies such as BBA and building control bodies such as nhbc and

00:44:19 building control bodies such as nhbc and lebc with contempt they did all of this knowing of the uniquely hazardous nature of acmpe

00:44:26 of acmpe push their products onto high-rise buildings to further their own commercial interests private sector companies involved in the refurbishment were chosen because they were cheap they operated in a culture of

00:44:39 were cheap they operated in a culture of complacency ambiguity and weak enforcement encouraged by government due allowance may be made for that but their directors chose to put profits

00:44:50 but their directors chose to put profits ahead of Resident safety and to exploit their known weaknesses of building control

00:44:55 control we've detailed in previous submissions what we see is they're devastating failings and merely trying to summarize them here

00:45:02 them here the architect Studio artificially suppressed their fees below the level which would have required an open tender and were appointed without Tender by the TMO in breach of the public procurement regulations

00:45:14 regulations they had no previous experience of refurbishing a high-rise none of Studio e staff had or made any effort to acquire the knowledge needed to work competently on grenfield they didn't know what they were doing

00:45:25 they didn't know what they were doing they shouldn't have taken on the on or persisted in the project which they were not competent to carry out they failed to ensure adequate fire safety engineering advice was obtained and they

00:45:37 engineering advice was obtained and they specified acmp cladding they knocked the refurbishment project off the rails from the start the fire Consultants X over and experienced fire safe safety consultancy

00:45:49 experienced fire safe safety consultancy were appointed as far Consultants by the TMO without tender and with a poorly specified brief neither the TMO Studio e nor Rhine used them properly at Key stages of the

00:46:00 them properly at Key stages of the project they used unqualified or junior staff for the project who notably failed to complete the fire risk strategy or even to consider the effect upon fire safety of installing a combustible

00:46:11 safety of installing a combustible rainscreen their involvement was a dangerous token gesture it was dangerous because it gave building control on others the false impression that far safety was being properly considered

00:46:24 properly considered the design and build contractor Ryden were pointed through a flawed and illegal tendering process from which it emerged as the lowest bidder following secret negotiations with the TMO a

00:46:35 secret negotiations with the TMO a process that smells strongly of corruption and agreeing to make further Savings of over a million pounds this led directly to the use of the cheaper face-fixed acmp cladding panels

00:46:47 cheaper face-fixed acmp cladding panels Rhoden neither had nor obtained specialist crowding or fire safety advice and cut Corners by not Consulting Studio e or X over on fire safety issues

00:46:58 Studio e or X over on fire safety issues the subcontractors both Harley facades and cep Architectural facades knew of the dangers of acmpe on high-rise and so both were complicit in ryden's cost cutting and the expense of health and

00:47:10 cutting and the expense of health and safety

00:47:11 safety Gerard Connell a fabricator at cep states that acmpe was easier to work with than safer varieties once again profits were put

00:47:23 varieties once again profits were put before people they all grievously failed the residence moving on to water rejecting the lfb's tests Dr stoyanov

00:47:36 rejecting the lfb's tests Dr stoyanov confirmed his opinion in module 7 that despite poor flow rate flow rates from most hydrants the quantity of water available for firefighting was more than adequate with the benefit of certain

00:47:47 adequate with the benefit of certain adjustments and that the Aerials deployed were theoretically capable of projecting water jets to or very close to the full height of the Tower

00:47:58 height of the Tower the aerial Appliance on the on the predetermined attendance for grenfell was removed in 2006 and despite being called for early in the incident no aerial arrived at grenfell until 1 32.

00:48:10 aerial arrived at grenfell until 1 32. we've submitted extensively on this subject and referred to our previous written and oral submissions we submit the failure to maximize the water flows to the pumps at groundfield

00:48:21 water flows to the pumps at groundfield was the result of systemic failings not any individual feelings of operational firefighters save only the failing to discharge the role of bulk media advisor estrogen adequate training there was no

00:48:34 estrogen adequate training there was no evidence that operational firefighters other than specialist bulk media advisors were given the necessary training to make the adjustments needed for example to use more than one hydrant to augment the supply to a single fire

00:48:46 to augment the supply to a single fire Appliance or to specify to Thames water the water flow they needed on the night for a particular Appliance or otherwise how to maximize the water flow this training failure is institutional

00:48:59 this training failure is institutional as to the poor discharge rate from hydrants Dr stoyanov would have expected the flow coefficients of the hydrants installed at grenfell to be higher than they turned out to be in this context he

00:49:10 they turned out to be in this context he referenced a paper which was published a year before the fire by a firefighter who'd carried out about 600 flow tests on fire hydrants in Southwest London and his conclusion was that about 20 were

00:49:22 his conclusion was that about 20 were inoperable and about 30 percent had flow rates less than 500 liters per minute in light of this paper Dr storynov concluded

00:49:30 concluded it seems that this is a very representative example of what's happening in London that most of these fire hydrants do not have the discharge characteristics which we expect them to have

00:49:40 have he identified a need for the fire rescue service to undertake periodic flow rate tests of hydrants in operation this the the lack of such flow rate tests was another institutional failure

00:49:55 tests was another institutional failure the incomplete and inaccurate information in the mobile data terminal which comes from the operational risk database was another institutional failing which further hindered operational firefighters on the night

00:50:08 operational firefighters on the night no blame attaches to individual firefighters for the poverty of this information there was no aerial on the predetermined attendance and there was thus no expectation on firefighters

00:50:20 thus no expectation on firefighters conducting a section 72d visit to a high-rise to consider the water supply set up for an aerial such as at grenfield Tower as can be seen from the list in appendix

00:50:32 as can be seen from the list in appendix one to pn633 which was cited extensively in phase one where there is no mention of the water supply for an aerial Appliance

00:50:41 Appliance likewise Thames water operatives were not given the training they needed to ask appropriate questions to elicit this information from the fire ground ER Thomas had made recommendations about

00:50:52 Thomas had made recommendations about water supply following the Harrow Court inquest into the deaths of firefighters Michael Miller and Jeffrey warnham and a resident Natalie close who all died on 2nd of May 2005 in flat 85 on the 14th

00:51:04 2nd of May 2005 in flat 85 on the 14th floor of an 18-story high-rise known as Harrow Court in stevenage Hertfordshire like so many others these recommendations had not been implemented by the 14th of June 2017.

00:51:17 implemented by the 14th of June 2017. these institutional failings flowed we submit principally from the deaf and deficiencies of national research and guidance for local Fire Rescue Services as reported by Dr

00:51:29 Fire Rescue Services as reported by Dr stoyanov

00:51:31 stoyanov for which individual firefighters should not be criticized Dr stoyanov expressly disavows any personal criticism of the individual firefighters he added in his oral

00:51:42 firefighters he added in his oral evidence that it was not practical for firefighters to have tested the mislabeled washout hydrant on the night the FB agrees and additionally submits that firefighters develop workarounds to

00:51:53 that firefighters develop workarounds to the best of their training and ability just one example on the night firefighter Keen who operated pump Appliance g272 supplying water to to a turntable ladder which is a type of

00:52:05 turntable ladder which is a type of aerial a213 told the police the water I was Supply only lasted less than a minute and then we had to wait another 20 seconds for the tank to fill back up after about 20 minutes to half an hour I

00:52:18 after about 20 minutes to half an hour I changed strategy and insist instead of giving them the full 10 bars I dropped it down to seven or eight bars so the supply was more continuous we say that was all he could do in

00:52:29 we say that was all he could do in accordance with his training and experience the response of the fire and rescue service how am I doing not bad the fbu recognizes that the role

00:52:41 not bad the fbu recognizes that the role of the fire and rescue service and the lfb is an important part of the inquiry the lfb did not cause the fire at Ground foot Tower and and did its best to respond to it

00:52:52 and and did its best to respond to it it has never been the position of the fbu all the members we represent that everything went as well as possible in their attempts to deal with the disaster there were failings and weaknesses there

00:53:04 there were failings and weaknesses there are lessons that must be learned for future fires not least because the materials used in the refurbishment of grenfell tower remain in place on many other high-rise buildings and still five years on and

00:53:16 and still five years on and three plus years after your recommendations there's still no National guidance on evacuating a high-rise

00:53:23 high-rise we're concerned however that by starting with a microanalysis of the emergency response in phase one and then returning to the Farm Rescue service in phase two the GTI risks distracting from the real

00:53:35 the GTI risks distracting from the real causes of the disaster and creating a scapegoat that would allow those truly responsible including senior politicians and company directors to evade responsibility firefighters risked their lives going

00:53:46 firefighters risked their lives going into the Blazing Inferno to try and rescue residents and extinguish the fire they and the control staff did their Duty professionally bravely into the best of their abilities in the face of a rapidly developing fire that was beyond

00:53:57 rapidly developing fire that was beyond anything any of them had ever experienced or trained for they followed their procedures and applied their training as much as the extreme conditions allowed Professor Torero calls for upskilling

00:54:08 Professor Torero calls for upskilling fire and rescue service Personnel to provide a greater level of Competency in all their functions Dr storynov's identified Water Supplies an area in which greater training is needed Professor Johnson has identified

00:54:20 needed Professor Johnson has identified Communications as another Mr mcgurk has identified section 72 D's amongst others the list is long the fbu welcomes these calls and fully supports better training

00:54:31 calls and fully supports better training for firefighters control staff and fast safety officers the fbu cautions however that significant additional additional investment of time and resources will be needed to implement these

00:54:42 needed to implement these recommendations not cuts and redundancies thank you

00:54:47 thank you the fire control switch for the lifting grenfell Tower I can see your your spirits Rising

00:54:55 I just want to to say a few words about about this we've already submitted extensively in writing and orally uh detailing the evidence and argument in

00:55:06 detailing the evidence and argument in support of the findings we asked the panel to make about the fire control switch

00:55:10 switch Steve Walsh KC for the London Fire commissioner broadly agreed with our opening submissions for module three also on day one one five it was impossible for the firefighters to use the lift or to protect residents

00:55:22 to use the lift or to protect residents from using it it was crucial to the emergency response that it worked but it didn't on the night this is because we say

00:55:29 say it wasn't maintained or tested before the fire but was allowed to remain blocked to build as debris following the main refurbishment we asked the panel to consider the submissions we've made

00:55:41 submissions we've made to analyze the evidence and to make following key findings one the fire control switch was not checked and tested by lift Engineers after the 19th of February 2016.

00:55:54 after the 19th of February 2016. to

00:55:55 to the fire control switch was blocked on the Night by Builders debris and for this reason could not be operated as to the first finding not being checked and tested by lift

00:56:06 not being checked and tested by lift engineers in the 16 months from the 19th of February 2016. some lift Engineers from Peters and Bureau Veritas now claim they did inspect and test the switch but their self-serving assertions are not

00:56:18 self-serving assertions are not supported by the defective condition in which the switch was found nor by any documentary evidence we've already submitted

00:56:26 submitted uh and we do not repeat here why we ask the panel to conclude this witness evidence is unreliable as to its condition the condition of the switch the WASP inspectors on behalf of

00:56:38 switch the WASP inspectors on behalf of operation North Lee found the switch was defective and observed as the mechanism on the finance switch on the ground floor was defective then we can assume this has not been examined by The Lift

00:56:49 this has not been examined by The Lift Service Company at regular intervals we agree with the WASP inspectors there is no record of any such check by Peters or Bureau Veritas lift Engineers after 19th of February 2016. the natural

00:57:02 after 19th of February 2016. the natural inference is that it did not happen unlike Mr haggerty's 16 months earlier that's the one on page 24 of pdr-6047 Mr Wallace didn't even record

00:57:14 pdr-6047 Mr Wallace didn't even record doing electrical safety switch check or any of the annual checks associated with an S-Type service visit following his service type visit his S-Type service visit on the 9th of May 20 2017.

00:57:29 and I don't need to to go into detail just to remind you that had anybody checked the um the the safety switches and devices

00:57:40 um the the safety switches and devices they must surely we contend have noticed that the automatic fire recall function wasn't working had been cut with straight ends and the potentially confusing presence of the Redundant fire

00:57:51 confusing presence of the Redundant fire control switch at the walkway level which needed to be removed and was still still there but no such mention was made we contend the inferences that they didn't check their safety switches and

00:58:03 didn't check their safety switches and devices

00:58:05 devices moving on to the blockage of Builders debris please screen side by side the photographs of the fire control switch taken in the grenfield tower on the 18th of April 2018 that I think will be the

00:58:17 of April 2018 that I think will be the one on the left yep that's the one on the left and um and photo 19 taking indeed apart I have asked you thank you very much I have asked you um sir members of the panel to look at

00:58:29 um sir members of the panel to look at this before the reason I'm asking you to look at it again isn't just by way of repetition it's because when I came to look at these photos again I noticed something

00:58:40 these photos again I noticed something which I hadn't noticed before and I wanted to point it out to you if you'd be kind enough to to look on the on Photo 19

00:58:48 Photo 19 that's the uh the same fire control switch

00:58:53 switch was taken out of grenfell Tower um it was actually removed from grenful Tower in July of of of uh 2018 following

00:59:04 Tower in July of of of uh 2018 following the WASP inspector's recommendation made in April of 18. but it was kept in a in a sealed evidence bag and taken to Deer Park where it was examined in a workshop

00:59:16 Park where it was examined in a workshop by police inspectors wasp inspectors on behalf of operation North League but if we look at bjg stroke 74.

00:59:29 bjg stroke 74. which is the one on the left of this photo 19 on the left

00:59:36 we do see some significant changes from the one that was taken out of grenfell Tower so look at look at first of all look at the left if you'd be kind enough

00:59:47 look at the left if you'd be kind enough to take the cursor to to photo 108 that's it I don't know if you're able to enlarge it a little bit maybe not to the full size but just a little bit

00:59:59 full size but just a little bit because the trouble is as we enlarge it it becomes a bit fuzzier that's fine thank you very much we can see there the encrusted Builders debris around the

01:00:10 encrusted Builders debris around the around the actual insides of the face plate and could you move the cursor up and down the Labyrinth the lab that's it perfect that's the Labyrinth where the where the drop key is supposed to drop

01:00:21 where the drop key is supposed to drop so obviously it's upside down at the moment because it's it's been taken the faceplate's been removed from the fire control switch and is hanging down but you have to imagine it's it's up the

01:00:32 you have to imagine it's it's up the right way when it's in place and you can see how that Labyrinth bar is encrusted with with Builders Dairy now look over the page to photo 19

01:00:44 now look over the page to photo 19 there it doesn't bear any comparison that is shiny you can see right into the edges of the labyrinth bar if you run your cursor up and down the leverage bar so people can see thank you and there on

01:00:56 so people can see thank you and there on the left you can see the where the edge which is which is perfectly clean shiny and clean now more significant if you go up to the top where the library

01:01:08 you go up to the top where the library if that's it where the Labyrinth bar is secured to the to the to the frame the switch frame that's like the two bookings

01:01:17 bookings um which which is the switch frame and the Labyrinth bar is secured to the switch frame by four screws you can see two screws up at one end and two screws down the other end and that's what I

01:01:28 down the other end and that's what I hadn't noticed before if you if you go back over to the switch to the Fire Control switches it came out of grimfield tower there's no sign of any screws

01:01:38 screws and in my submission um that that it supports our submission that the

01:01:47 that the um that the file control switch we see in photo 19. uh was the result of substantial cleaning we can see Shiny bits on the faceplate it's obviously been wiped with cloth

01:01:59 been wiped with cloth and we can see that the actual mechanism of the fire control switch has been extensively cleaned but because of the screws we can see that it must have been dismantled cleaned and then reassembled

01:02:13 cleaned and then reassembled and and that's the condition of the fire control switch which was then examined by

01:02:20 by Mr horn and Mr Hawkins and others in Deer Park on the 15th of February 2019. so when Mr halkins describes a quarter

01:02:31 so when Mr halkins describes a quarter of a teaspoon of Builders debris retrieved from the fire control switch he's talking about the fire control switch

01:02:39 switch as cleaned he's talking about the Builder's debris which remained after that cleaning operation had taken place I'm not making casting any aspersions

01:02:50 I'm not making casting any aspersions over the cleaning of the switch the purpose of its investigation in Deer Park on the 15th of February 2019 was to examine it it's very hard to

01:03:02 2019 was to examine it it's very hard to see how it could have been examined without being cleaned from a technical engineering perspective but so far as as drawing conclusions about the extent of its uh of the

01:03:14 about the extent of its uh of the Builder's debris that blocked it in grenfell Tower we have to make due allowance for the fact that it has been cleaned there and I ask you please to to look at the photograph

01:03:26 look at the photograph um as as it came out of grenfell Tower and to bear in mind that uh the most likely explanation for it not being turned and operated effectively was that

01:03:38 turned and operated effectively was that it was it was jammed with Builders debris

01:03:44 so a few more points on the 15th of March site visit one the independent wasp inspectors uh visually inspected the ground floor fire control switch in grateful Tower without

01:03:56 control switch in grateful Tower without removing the face plate and reported it had not been damaged by either fire or water

01:04:00 water so if you look at the upper photograph on page 108 I wonder if you could just like bring that that's it so that's how it was in grenfell Tower and you can see

01:04:11 it was in grenfell Tower and you can see no sign there like the WASP inspectors reported of damage of the switch by far or water it's not as if it's in a part of the wall that is there's obviously been subjected to fire

01:04:23 there's obviously been subjected to fire or water

01:04:25 or water on the 18th of April they returned for their site visit too these are the WASP inspectors and and they found and if we could just reduce the size of the pictures to look

01:04:37 reduce the size of the pictures to look at the text

01:04:42 they tried to operate it because they say on the left there the fireman switch was difficult to operate and then the face plate was removed to determine the reason for failing to operate the switch

01:04:53 reason for failing to operate the switch we say it don't need any explanation it's it's obvious from the photograph what was the reason it was blocked

01:05:03 they couldn't operate the switch despite using the correct drop release key and applying reasonable force and this was finally and for the first time accepted by Mr helkins at the end of his oral evidence to the inquiry on day 165. too

01:05:16 evidence to the inquiry on day 165. too late regrettably for him properly to consider its significance it shows we submit that fire control switch could not be operated on the night even using the correct drop release key and applying reasonable

01:05:27 release key and applying reasonable Force

01:05:28 Force and B that it was the Builder's debris that stopped it operating on the night there was the WASP inspectors recorded and we can see this that uh the faceplate was removed to

01:05:40 that uh the faceplate was removed to determine and at the bottom and towards the bottom of the page we discovered that the mechanism was seized and damaged stroke deformed and then they observed at the end of their report this is Page 132 of uh of

01:05:53 their report this is Page 132 of uh of of Mr hawkins's appendices that's their report that the drop key used to operate the fire and switches proved to be very difficult to operate and may prevent the farming from Gaining use of the lift to

01:06:05 farming from Gaining use of the lift to fight the fire and they recommended a replacement with a triangular type key so

01:06:12 so um do ask you sir members of the panel to compare those two photographs and draw the conclusions that we're asking you to draw that does unfortunately uh clash with Mr

01:06:25 that does unfortunately uh clash with Mr hawkins's opinion and he has formed a completely opposite opinion we say that that opinion is unreliable it's based upon his factual error

01:06:37 upon his factual error about the extent of the blockage found by the WASP inspectors and that error that factual era has led to his flawed conclusion at paragraph of 163 of his supplementary report that

01:06:48 163 of his supplementary report that overall in my view considering the amount and size of debris on the switch and the testing carried out if an ordinary authorized adult had used a fitting Express drop key in the fire control switch and has used a reasonable

01:06:59 control switch and has used a reasonable amount of force it's likely the debris would have cleared as it did for us in the testing there he was only talking about the little bit of debris that that was that remained behind which still blocked the

01:07:10 remained behind which still blocked the operation of the micro switch on on February the 15th

01:07:18 foreign

01:07:21 thank you for your patience I've just got a few words to say about the smoke control system and then I come to a conclusion we've set out the fbu submissions on smoke control and it's designed by PSB

01:07:34 smoke control and it's designed by PSB and don't repeat them here but we do ask you to take those into account particularly on the unreliability as we say of Mr Lay's expert evidence where it differs from Mr lane from Dr Lanes

01:07:45 differs from Mr lane from Dr Lanes and we endorse the submissions already made

01:07:48 made today by Stephanie barwise Michael Mansfield and Adrian Williams and Casey on behalf of the bsrs so conclusion

01:08:04 [Music]

01:08:09 what has been demonstrated during the last five years of this inquiry is the widespread failure to prioritize fire safety what must come out of it is a greater

01:08:22 what must come out of it is a greater awareness of fire risks and the enormity of their consequences if they materialize that direct that deregulation must give way to Life Safety

01:08:35 way to Life Safety there must be more investment in the training of those involved in ensuring and enforcing fire safety and providing Fire and Rescue Services there must be greater respect for social

01:08:47 there must be greater respect for social housing and those who live in it there must be more listening to those affected by fire risks in particular the firefighters who lay down their lives

01:08:58 firefighters who lay down their lives and put them on the line there must be proper oversight of the implementation of recommendations coming out of careful investigations like this

01:09:10 like this thank you for your patience thank you very much Mr Secret

01:09:15 well now uh finally this afternoon we're going to hear the closing statement by Mr Stephen Walsh King's Council on behalf of the London Fire commissioner saying Mr Walsh when you

01:09:28 saying Mr Walsh when you already

01:09:31 already we shall be pleased to hear from you

01:09:43 and I may say we're pleased to see you here in person well well done thank you I always intended to come actually that the the remote issue was just just in case there were some major issues

01:09:55 case there were some major issues um thank you very much so good afternoon and good afternoon Mr fan and Mr ackball uh just while it's in my mind because I haven't heard those submissions before the submissions that have just been made

01:10:07 the submissions that have just been made by Mr seaward uh revised submission concerning the lift key mechanism uh are I think persuasive and probably deserve renewed

01:10:18 and probably deserve renewed consideration so we'd endorse them to that extent and say no more about it than that so in common with others who have given who have made submissions

01:10:29 who have given who have made submissions to you today I uh in the certainly in the time available this afternoon I won't be taking you through the entirety of our written overarching statement is obviously now a matter of

01:10:41 statement is obviously now a matter of public record for all to read and I know that you sir and and your colleagues will carefully consider the issues which are addressed in it and take them fully

01:10:54 are addressed in it and take them fully into account in your work on on the phase two report of course the same applies to the numerous statements which have been provided to you by on behalf of the LFC in both phases

01:11:07 by on behalf of the LFC in both phases of the inquiry both written and oral the most recent of which were the closing statements for modules 5 and 6. those statements dealt

01:11:18 modules 5 and 6. those statements dealt with much of the evidence which we have heard during phase two to a significant degree they perform many of the functions which this overarching written statement we have

01:11:29 overarching written statement we have provided to you is intended to do but that said

01:11:34 that said in this current overarching statement to in which a degree of repetition is inevitable uh we have sought in three parts to address from a slightly different

01:11:45 address from a slightly different perspective the most important the key most important aspect of the phase two evidence insofar as it impacts on emergency responses to high-rise

01:11:56 emergency responses to high-rise residential fires the first part of the written overarching statement clarifies in many instances affirms the key

01:12:08 in many instances affirms the key concessions or admissions that have been made by the lfb through the candid evidence of past and present employees during phase two in light of those concessions the second

01:12:21 in light of those concessions the second part of the statement highlights previous submissions made to you on behalf of the Brigade which have been confirmed and strengthened by the context the rich context which the

01:12:33 context the rich context which the evidence in phase two is provided and that that includes issues which deal with the single singular nature of the fire without going into detail about any of this the principal cause of the fire

01:12:44 of this the principal cause of the fire which you addressed of course in Phase One in your phase one report but no doubt will revisit again in phase in the phase two report and the Reliance on the regulatory system the building

01:12:56 regulatory system the building regulations and others including the important evidence in module 6B concerning the role of the responsible government department and others

01:13:08 government department and others and the third part of the statement elaborates upon the continuing challenges faced by fire and Rescue Services in planning for and responding to fires in

01:13:21 planning for and responding to fires in high-rise residential buildings where there has been as there was at Granville Tower a fundamental subversion of the system of fire safety regulation

01:13:32 system of fire safety regulation which was revealed so shockingly in relation to grenful Tower of course in various phases for various modules of phase two and that is for the vital

01:13:43 phase two and that is for the vital purpose of affecting meaningful changes for the future which is really what I'm going to address you about in the in in the time I have available this afternoon the issues in that third part of the

01:13:55 the issues in that third part of the statement concerned the emergency evacuation of entire buildings which are built and designed to a certain principle

01:14:04 principle control room procedure and the challenges which will continue to exist there fire fighting in light of the restrictions which the regulations provide risk information gathering and

01:14:17 provide risk information gathering and the often underestimated sometimes to some extent I'm recognized but extremely important issue of firefighters safety you'll recall all the evidence which

01:14:29 you'll recall all the evidence which which has been reduced about that and submissions which we have made in previous submissions but we've we've we've repeated it effectively in the written statement so all of that can be gleaned from the retina overarching

01:14:41 gleaned from the retina overarching statement and indeed from previous statements and oral submissions um so I won't expound upon those further but I do need to spend a little time on

01:14:52 but I do need to spend a little time on the concessions which are dealt with in the first part of the written statement which were made by a number of past and present officers and employees of the Brigade

01:15:04 Brigade in both phases of the inquiry as I hope you recognize and I think you have been kind enough expressly to do so previously the London Fire commissioner and the organization

01:15:16 Fire commissioner and the organization he leads have been fully committed to assisting the inquiry with its investigations in a number of ways which are identified in the written statement

01:15:27 are identified in the written statement 127 rule 9 witness statements were provided at your request in addition to the hundreds of witness statements which were provided to the police and about a hundred I think it's

01:15:38 police and about a hundred I think it's a hundred of those persons attended this inquiry to answer detailed questions from your Council on a number of us use

01:15:50 and during that evidence former and present senior staff made Frank concessions on a number of issues by

01:16:01 concessions on a number of issues by accepting shortcomings in operational planning and training in the Years leading up to the grenfell tower fire and accepting unequivocally where

01:16:12 and accepting unequivocally where certain practices should have been managed better

01:16:16 in your phase one report sir you recognized the many acts of extraordinary bravery and selflessness of firefighters individual firefighters

01:16:28 of firefighters individual firefighters who responded to the great to the grenful tower fire and I've said before the London Fire commissioner is very grateful to you for that recognition it is as we have said before I think I

01:16:40 it is as we have said before I think I said this in phase one at the beginning in the DNA in the DNA of all fire and rescue service Personnel to do all that they can to protect and save life that's

01:16:52 they can to protect and save life that's what they did on the night of the Granville Tower fire but of course this inquiry focuses on systemic issues

01:17:01 um which are the responsibility of senior staff but of course those senior staff uh in nearly all cases came through the

01:17:12 uh in nearly all cases came through the ranks

01:17:13 ranks and share that same DNA so for those senior staff who claim to give evidence in both phases often having retired some years ago

01:17:25 having retired some years ago to assist the inquiry in an open manner their approach to the work they did when they were at the Brigade or are still at the Brigade was at all times driven by a

01:17:36 the Brigade was at all times driven by a genuine desire to do the best they could in the interests of keeping londoners safe that's what drove them they accepted them that mistakes were sometimes made

01:17:48 sometimes made sometimes significant mistakes which is why they made those Frank concessions accepting where things could and should have been done better and may I make it clear in case there is any

01:18:00 I make it clear in case there is any doubt about it that there was never any point

01:18:05 point when any of them even considered seeking an undertaking from the attorney general through you that they're evidence to you would not be used against them in other

01:18:16 would not be used against them in other proceedings it just wasn't considered by any of them or the Brigade uh in the written statement a number of the key concessions our admissions are set out as I've said they include

01:18:28 set out as I've said they include matters connected with the development of policies and procedures training particularly in control pre-planning risk information gathering and Communications

01:18:41 and Communications and the London Fire commissioner reaffirms those concessions in the form set out in the written statement you can see how that's done as he did when he gave evidence

01:18:53 he did when he gave evidence and apologizes for the shortcomings they reflect and to anyone affected by them

01:19:03 but what really matters is affecting real change where change is needed and you will recall what the current commissioner said about that in his

01:19:15 commissioner said about that in his module his evidence in module five a used this quote before but it's totally important he said this I think the public should judge us on the outcomes we deliver to London

01:19:27 outcomes we deliver to London so I don't ask for trust I don't think we deserve to ask for trust until we demonstrate different outcomes and to that end an extensive account of the work which

01:19:39 an extensive account of the work which the Brigade has been doing since 2017 has been provided in a separate statement to you quite a long one

01:19:48 one detailing the extent and nature of those reforms her reforms which have been implemented and that includes radical improvements to the system of assurance which is particularly important from the

01:20:00 which is particularly important from the perspective of those changes that statement Builds on the lfb Improvement progress report of October 2021 which was prepared by former

01:20:12 2021 which was prepared by former assistant commissioner Andy Bell a summary of which of course could be found in the in the lfc's closing submissions for modules 5 and 6A but it's obviously been updated in that more recent

01:20:24 been updated in that more recent statement uh signed by former assistant commissioner Andy Bell so it's uh may I return now

01:20:35 so it's uh may I return now to where I finished in my last relatively brief address to you at the end at the end of module 6B by emphasizing the vital importance of the

01:20:46 emphasizing the vital importance of the rich context which the evidence in Phase 2 has provided to so many of the issues which were explored with the lfp Witnesses in phase one at the conclusion of the phase two

01:20:59 at the conclusion of the phase two evidence uh you encapsulated what the Inquirer is thorough and uncompromising process exposed in phase two I quote you here as the many decisions

01:21:12 here as the many decisions taken by many different people over the course of many years that conspired to create a building which in June 2017 was vulnerable to a

01:21:24 which in June 2017 was vulnerable to a catastrophic fire resulting from the failure of a common type of domestic appliance

01:21:33 with that in mind I want to stand back in the time I've got left here this afternoon and look at a small number of interlinking actually overarching issues which are crucial we

01:21:46 overarching issues which are crucial we say to a proper understanding of the lfb's response to the fire at Grumble Tower

01:21:52 Tower together

01:21:54 together they provide the central context to the brigade's primary acceptance concession that it did not plan for or train incident commanders or

01:22:05 or train incident commanders or firefighters to abandon the stay put strategy for an entire building in favor of carrying out a simultaneous evacuation of the entire population

01:22:16 evacuation of the entire population the first of those issues firmly established of course in the course of

01:22:23 course of phase two is the series of Revelations uh that the building had been allowed by the cumulative actions and emissions of course of several

01:22:34 and emissions of course of several people and organizations who were responsible for its safety to present a grave danger to Residents in case of fire

01:22:44 fire but also to the emergency services who respond who have to respond to fires of that kind

01:22:51 that kind the second issue concerns the state put principle itself to which I'm fresh I will return yet again in a moment but I'll be as brief as I can and the third issue is that the grenfell tower fire

01:23:03 issue is that the grenfell tower fire was as a whole incident unprecedented and on the admission of the Brigade was not foreseen whether or not that lack of foresight was reasonable of course as a matter

01:23:15 was reasonable of course as a matter that you make well consider it during your deliberation on the phase two report but nonetheless it wasn't foreseen and I'll deal with the second and third there's two issues together because they're inextricably linked

01:23:28 because they're inextricably linked the stay put strategy and as I've said I will be brief having addressed you so many times on this topic before but we have reason to need to reiterate the basics

01:23:39 need to reiterate the basics it is simply wrong to categorize the single safety measure stay put

01:23:47 stay put which underpins all of the multi-layered active and passive fire safety measures which are required to be in place to support it as a Dogma

01:23:58 as a Dogma or that Reliance on it is to take a dogmatic approach it's quite the contrary because whether we like it or not

01:24:09 because whether we like it or not the whole design construction and maintenance of buildings such as grenful Tower is governed by the staple strategy and no other as we know and still is

01:24:24 and no other as we know and still is forgive me for repeating yet again the important summary which Dr Lane provided in her phase one report but it seems it needs repeating again and again

01:24:35 again and again she said this the fire protection measures must be constructed and then maintained to ensure they are fit for purpose in the event of Fire

01:24:46 event of Fire the stay put strategy is provided through design construction and ongoing maintenance all building occupants including the fire brigade rely on it in the event of fire it is the single

01:24:58 the event of fire it is the single safety condition provided for the design of high-rise residential buildings in England the statutory guidance makes no provision no provision within the building for anything other than the

01:25:10 building for anything other than the state put strategy so the principles upon which that strategy for high-rise residential buildings are founded or well known to the inquiry course uh they have been the subject of expert

01:25:23 uh they have been the subject of expert evidence

01:25:24 evidence at both stages it's common ground that among certainly among the inquiries experts and others that the regulatory regime makes the following assumptions

01:25:37 regime makes the following assumptions and these are important assumptions when looking at what can fire rescue services do in the future first of all only single unit fires are anticipated or allowed for

01:25:48 anticipated or allowed for multiple fires on multiple levels are not anticipated or allowed for for example by stipulating the requirement for dry Rising Mains which can be accessed at each floor level internally

01:26:01 accessed at each floor level internally but which are incapable of effective operation on more than two or maybe three floors at a stretch at one time vertical or lateral fires on the

01:26:13 vertical or lateral fires on the exterior are not anticipated or allowed for the regime assumes and indeed only provides facilities for firefighting internally I'll come back

01:26:24 firefighting internally I'll come back to that in a moment and simultaneous evacuation crucially on a large scale is not anticipated relatable so it follows that in buildings in the UK and overseas which

01:26:36 buildings in the UK and overseas which are required by the regulations to provide for evacuation strategies and so on in case of fire those kind of buildings must be distinguished for the purposes of comparatives from high-rise

01:26:49 purposes of comparatives from high-rise residential buildings with a stay put strategy

01:26:53 strategy for example

01:26:56 in the UK buildings such as Care Homes hotels offices all sorts of other buildings

01:27:02 buildings and residential buildings overseas such as the lower cross building in Melbourne and the torch in Dubai are all required by law to provide systems which support

01:27:14 by law to provide systems which support the simultaneous evacuation of occupants of the entire building in case of fire just as an example in relation to the lacrosse building and

01:27:26 in relation to the lacrosse building and the torch

01:27:27 the torch that's achieved by the provision of safety measures such as modern building-wide alarm systems often phased by height of the of the floors with

01:27:39 by height of the of the floors with regular fire drills to occupants Sprinklers and other fire suppression measures additional evacuation stairwells separate from those used by fire and Rescue Services

01:27:50 fire and Rescue Services Refuge areas which assist in the evacuation of the disabled and vulnerable and firefighting lifts expressly for the use in the evacuation of occupants grenfell Tower

01:28:04 of occupants grenfell Tower and other high-rise buildings with the state could put strategy had have none of these measures in place they are not required or expected to

01:28:15 they are not required or expected to have them because they are deemed by the regulatory system to be unnecessary on the basis that if the buildings are broadly compliant with the regulations a

01:28:26 broadly compliant with the regulations a simultaneous evacuation of the entire population will never be required the basic Assumption of the regulatory system

01:28:35 system so

01:28:36 so when the stay put strategy entirely fails

01:28:40 fails in the event of Fire and Rescue Services are left with addressing a situation which is neither provided for by the regular regulatory regime nor the

01:28:52 regular regulatory regime nor the building in question why because it's not supposed to happen because the regulatory regime is expressly intended to ensure that it cannot happen and the reasons then why it is

01:29:04 and the reasons then why it is imperative therefore that buildings designed and built with a stage put strategy must be maintained appropriately to support that strategy in a thug thorough and rigorous manner

01:29:16 in a thug thorough and rigorous manner have been explained in previous statements that we've made to you before now

01:29:24 now the London Fire commissioner does not suggest that full compliance with the regulations should be assumed by the RFB or any other fire rescue service in the country and of course a number of

01:29:36 country and of course a number of warnings have been given by the Brigade to government over the years in relation to the dangers of non-compliance as you know

01:29:45 know but and this is such an important point in this case compliance is expected

01:29:55 at least to a broad degree when compliance has been checked and verified by local Authority building control departments

01:30:06 departments and when certificates of completion following construction or major alterations are issued and that is why the certificate of completion issued by rbkc building

01:30:19 completion issued by rbkc building Control Department for grenfell Tower following the refurbishment is so terribly significant in this case

01:30:29 that said as uh Stephanie barwise King's Council said this morning and we agree with her in the case of grenfell Tower so much had gone wrong before the

01:30:42 so much had gone wrong before the certification process was completed that the building Control Department would probably not have known of quite a bit of what had gone wrong previously

01:30:54 so if such buildings are maintained so as to fundamentally undermine the staple strategy upon which they were designed and built it must be acknowledged that fire and Rescue Services are faced

01:31:07 that fire and Rescue Services are faced with an immense impediment and I use that word advisedly an impediment to any emergency response which the regulations don't provide for and more importantly the buildings

01:31:19 and more importantly the buildings their government don't comply for perhaps the starkest example of this is the absence of any meaningful requirement in the regulations to enable the

01:31:31 in the regulations to enable the evacuation of the vulnerable or disabled in a building which is designed and built according to a stay put strategy whether assisted or otherwise and I I

01:31:42 whether assisted or otherwise and I I will come back to this just before I that particular issue just before I conclude

01:31:48 conclude of course the LFC supports and shares the inquiries primary objective namely uh the imperative that meaningful changes are made in an Endeavor to

01:31:59 changes are made in an Endeavor to ensure that this tragedy never occurs again

01:32:02 again and such changes can really only be affected and sustained in part through the recommendations that you will make in due course if there is a proper understanding

01:32:13 understanding of the challenges faced by fire and Rescue Services in preparing for responding to and seeking to overcome where reasonable reasonably possible and

01:32:24 where reasonable reasonably possible and that's what it's about significant failures on the part of building owners to reach such an understanding it's also essential to acknowledge the fact the buildings of this kind can't be compared

01:32:37 buildings of this kind can't be compared to the majority of stock in the built environment nationally or internationally which actively provide for the evacuation of occupants in case of farm

01:32:48 of farm and similarly to make any sense of how the tragedy at Granville Tower can be avoided in the future

01:32:56 future it is necessary frankly to accept that serious and and in some respect inescapable consequences flow from allowing or positively developing a

01:33:07 allowing or positively developing a staple building to prevent to present such serious risks to the lives of residents

01:33:14 residents so a few words on foreseeability which we have touched upon in in the written statement the LFC does not seek to to dilute

01:33:26 dilute it's Express acceptance that from a very early stage in phase one that while the lfb and other Farm Rescue Services identified and addressed certain foreseeable risks associated

01:33:39 certain foreseeable risks associated with high-rise residential buildings the possibility of a devastating fire on the scale of grenfell Tower was not foreseen and it wasn't planned for

01:33:50 for and that is the reason why policy and training was not developed to respond to such a disaster either operationally or in the control room informed we say and guided by the

01:34:03 informed we say and guided by the well-established one must remember this the well-established and historically effective

01:34:09 effective design principle relating to high-rise buildings that is State put it was not contemplated that an entire multi-story residential building which was built built and

01:34:20 building which was built built and designed with a staple strategy might require

01:34:24 require simultaneous simultaneous evacuation of its entire population by reason of the total failure of his external facade cladding system and its

01:34:35 external facade cladding system and its internal active and passive fire measures which actively promoted the spread of fire as I have said whether the absence of such foresight can be regardless reasonable of course will be

01:34:46 regardless reasonable of course will be a matter for you to consider but it does Remain the position of the London Fire commissioner as he said during his evidence to you quote the totality

01:34:58 evidence to you quote the totality the scale and the extremity of the of that failure of every single part of Regulation and human behavior that should underpin it would have been difficult to project

01:35:11 and here I'd just come to some of the expert evidence because some support for that position some support for that position

01:35:19 position is found in the phase two report of Mr mcgurk your firefighting expert when he was addressing external firefighting he recognized the singular

01:35:31 firefighting he recognized the singular nature of the gramful Tower of fire in the context of external fire spread in the cladding system and the formidable quote formidable challenges faced by fire and Rescue

01:35:43 challenges faced by fire and Rescue Services when he said this quote from the outset I would state that any evaluation of the effectiveness of external firefighting is extremely

01:35:54 external firefighting is extremely difficult

01:35:55 difficult this is because of the multiple obstacles associated with design and access difficulties as well as numerous Construction and building design failures but most especially the impact

01:36:07 failures but most especially the impact of the cladding however I do emphasize that the fact that the internal firefighting provisions of Grandville Tower failed

01:36:18 provisions of Grandville Tower failed simultaneously with the failure of virtually all of the other passive and active fire safety features meant that the standard operational firefighting method normally employed for high-rise

01:36:30 method normally employed for high-rise buildings by the lfb could not be implemented this presented a truly formidable challenge to the lfp especially to the first cruise

01:36:42 first cruise expressed simply gramful quickly moved from being a compartment fire to multiple compartment fires to multiple compartment fires

01:36:54 to multiple compartment fires concomitant with the building itself being on fire and in such in the circumstances meant that the op any operational response was always going to entail extensive

01:37:07 always going to entail extensive improvisation he finishes this part of his evidence by saying this I think it is unreasonable therefore

01:37:14 therefore to suggest that the lfb ought to have anticipated an external fire of this nature and it is against this backdrop that my subsequent comments should be considered

01:37:26 subsequent comments should be considered well that's his that's his evidence in his phase two report but of course with that recognition of the impact on the operational response

01:37:37 the impact on the operational response which the dynamic and multifaceted nature of the fire had it's it's it's convenient now for me to turn to the evidence of Dr stoyanov

01:37:48 evidence of Dr stoyanov which has been addressed in a separate statement to you under module 7. can I make it very clear that throughout phases one and two

01:37:59 that throughout phases one and two of this inquiry the experts instructed by you by the inquiry have without exception provided highly informed and cogent evidence which has been of

01:38:11 cogent evidence which has been of significant value to the LFC and Farm Rescue Services more broadly for the purposes of developing policy and procedure for the future across a wide range of topics Dr stoyanov is no

01:38:24 range of topics Dr stoyanov is no exception

01:38:25 exception his unquestionable standing as a leading expert in his field is underpinned by his impressive history of academic research

01:38:34 research you can tell there's a however or a butt coming on here it's it's coming now in common with professor torreiro who supports certain of Dr stoyanov's

01:38:46 who supports certain of Dr stoyanov's findings he doesn't though suggest or purport to be an expert in the provision of operational firefighting or rescue operations and

01:38:58 firefighting or rescue operations and nor does he have practical experience of it and that's not a criticism of him that's just what he accepts in a straightforward way so while the LFC has found his evidence

01:39:09 so while the LFC has found his evidence to be extremely informative and of a high degree of utility on a variety of issues it must be we say utilized in a practical way by according to the realities actually

01:39:21 by according to the realities actually which Fire and Rescue Services in a dynamic operational incident scenario face

01:39:28 face and given that there has been no live evidence from the lfp to explain how and what by what means certain of Dr stoino's findings might be impacted by such practical considerations

01:39:40 such practical considerations the attention of your attention attention of the inquiry is drawn to the statements of Deputy assistant commissioner Philip Morton who touched

01:39:51 commissioner Philip Morton who touched upon these issues and provided statements to you in the most recent of those statements Mr Morton provides examples of common real life scenarios faced by fire and Rescue Services which

01:40:03 faced by fire and Rescue Services which demonstrate an occasional divide between academic Theory and practice in the field

01:40:10 the field and there's been so much harrowing evidence of the dangerous conditions which existed both inside and outside Grenville Tower on the night of the fire one recalls

01:40:22 on the night of the fire one recalls um

01:40:24 um in Phase One the extraordinary bravery of the metropolitan police officers Who provided with the use of their Shields cover for firefighters entering

01:40:36 Shields cover for firefighters entering and leaving the building while debris rained down from above just one example among the Practical examples given by Mr Morton in his statement which I won't

01:40:47 Morton in his statement which I won't address here in full obviously he speaks of the real challenges on the fire ground when he said quoting again here at the grenful tower fire activity took place at night

01:40:58 place at night under falling debris in an area cluttered with parked cars and other buildings this leads to a number of challenges including the sighting of appliances aerial appliances require a flat surface

01:41:11 aerial appliances require a flat surface in order to maximize water jet height and the laying of hose to optimize flow just pausing there I'm going to add here and of course on that night there was a

01:41:22 and of course on that night there was a constant concern that the hoses which were laid out and it takes a fair period of time to laid them out would be damaged by the falling debris so that had to be considered

01:41:33 had to be considered uh Mr Morton then speaks of the tests which were done at the fire service College

01:41:38 College he says of that it was possible at the fire service College in sort of quasi-perfect conditions to cite multiple multiple appliances directly adjacent to each other on flat

01:41:50 directly adjacent to each other on flat and clear surfaces he's dealing there with Dr stoyanov's suggestion that you'd combine a series of fire engines pumps so as to improve the flow rate

01:42:01 so as to improve the flow rate the the point that Mr Morton is making is that that simply wouldn't have been possible at grenfold her and it's often possible uh says Mr Morton it is often not possible

01:42:13 Morton it is often not possible to attain maximum height and throw of an aerial Appliance in the operating environment during due to trees cars balconies and other things that may impede access and the challenge is

01:42:25 impede access and the challenge is heightened he says when there is time pressure to set up an appliance and immediately immediately bring water to bear on the Fire and of course leaving his statement

01:42:37 and of course leaving his statement aside it's also important to remember that the deployment of aerial appliances at grenfell Tower was only possible on two of the four elevations of the town because of axis problems and that

01:42:49 town because of axis problems and that isn't an uncommon occurrence it reflects the fact that the building regulations because they don't anticipate external firefighting the building regulations

01:43:00 firefighting the building regulations make no provision or requirement to provide access for aerial appliances to high-rise residential buildings

01:43:10 so in short on that issue the LFC urges you gently as it were because we have a great deal of respect for Dr storenov but nonetheless to exercise caution

01:43:21 but nonetheless to exercise caution when making findings based on his evidence Dr sternov's evidence noting of course the persuasive submissions of Thames water which you will hear later this week about the Practical maximum

01:43:34 this week about the Practical maximum use and reach of water which might have been achievable on the night of the fire say no more about it than that so returning quickly to the issue of evacuating a State Building

01:43:45 evacuating a State Building yeah it is extremely important to acknowledge that during a fire the evacuation of those directly affected by viral smoke while leaving

01:43:56 affected by viral smoke while leaving others in place is not occasionally it's been described as that the partial abandonment of the stay put strategy it is that actually the application of

01:44:07 it is that actually the application of the state put strategy the brigades policy and procedure for example of sectorization uh to implement partial evacuation of such buildings is well established and just for example it was implemented at

01:44:20 just for example it was implemented at Shepherd's Court but if residents of an entire building are directly affected and likely to become so that is a very different

01:44:31 become so that is a very different matter because the entire building is the fire sector in such circumstances the abandonment of the only fire safety strategy for buildings of this kind is and can only

01:44:42 buildings of this kind is and can only be a dangerous measure of Last Resort while Fire and Rescue Services will do all they can to affect Rescue and assist in a an emergency evacuation such a

01:44:55 in a an emergency evacuation such a course of action will inevitably require many residents those who are able to fend for themselves when firefighters can't reach them in a perilous attempt to escape the building through

01:45:06 to escape the building through life-threatening toxic gases with limited visibility down several flights of stairs and so on and as we know from the evidence in phase two such an appalling State of

01:45:19 phase two such an appalling State of Affairs only arises where a building is allowed to fail in all aspects of fire safety affecting the entire building

01:45:30 the entire building effectively again as an Inferno that's what happened to Grenville Tower it had never happened before in the UK in a stay put high-rise residential

01:45:41 in a stay put high-rise residential building and in that basic sense it was unprecedented but of course the LFC accepts that notwithstanding the nature and scale of the Granville Tower fire there were many

01:45:53 the Granville Tower fire there were many elements of operational pre-planning information gathering and training particularly in control which could and should have been done better in the Years leading up to the 14th of June

01:46:05 Years leading up to the 14th of June 2017 that much as as I've said has been expressly acknowledged by the commissioner he also accepts the commissioner also accepts that certain characteristics

01:46:16 characteristics of the fire at grenfell Tower were foreseeable and that they should have been planned for

01:46:23 for in relation to some of those features the lfb had policies and procedures in place which had been the subject of training however you are would you bear with me on this particular Point your

01:46:34 with me on this particular Point your urge to pay careful attention to the extent to which on a fair analysis

01:46:41 analysis a presumed understanding or awareness of the appropriate operational response to a fire on the scale of grenful tower can be extrapolated from knowledge of the

01:46:52 be extrapolated from knowledge of the constituent risks which were present for example the lfp is well aware that breaches of compartmentation in high-rise residential buildings are a

01:47:03 high-rise residential buildings are a relatively common occurrence and that strict compliance with compartmentation requirements can't be relied on it's entirely accepted such breaches occur in a variety of ways poor

01:47:16 breaches occur in a variety of ways poor internal fire stopping it's a fire breaking out through windows and facades entering through Windows above via the coanda effect or burning

01:47:27 above via the coanda effect or burning in child debris falling into open Windows below has occurred at Blackwell house in 2009 which of course did not involve extensive fire spread over a

01:47:39 involve extensive fire spread over a continuous facade cladding system um I I do need to spend a minute or so on this just to be clear about what was being learned or what should have been learned

01:47:51 learned from the lack of fire the primary causes of the severity of the lateral fire were the serious internal failings in compartmentation the most serious of

01:48:02 in compartmentation the most serious of which

01:48:03 which was the use of defective or flammable materials

01:48:07 materials which should have been fire resisting which allowed fire to break out from a flat

01:48:13 flat take hold of in the concealed void above a suspended ceiling in the common Corridor Public Access race along the whole length of that Corridor void which was fueled by a

01:48:26 Corridor void which was fueled by a variety of flammable materials within it spread below into the corridor itself in engulfing the entire Corridor and therefore preventing any escape from the flats that gave access onto it and to

01:48:39 flats that gave access onto it and to re-enter another flat with fatal consequences and that's an oversimplification obviously but it puts it sort of in a nutshell

01:48:49 nutshell of that terrible incident but it was the serious breaches of internal compartmentation among other things which was the focus of the subsequent training package provided by the

01:49:01 training package provided by the Lackland house case study just to make that clear

01:49:06 um I come now to the final topic for this this afternoon and returned to my earlier observation that one of the starkist starkest examples of the consequences of allowing

01:49:18 examples of the consequences of allowing a staple building to become a serious danger to all residency in case of fire is the absence of any meaningful requirements in the building regulations to provide for the evacuation in an

01:49:31 to provide for the evacuation in an emergency or otherwise of the vulnerable or disabled of course I have in mind uh the recommendation which you made to government on this issue in your phase

01:49:43 government on this issue in your phase one report in relation to peeps and now the government has relatively recently consulted on proposals that in the London Fire commission's

01:49:54 the London Fire commission's Commissioner's opinion do not go far enough

01:49:58 enough in addressing the intent of that recommendation while the lfp supports the government's initial focus on buildings with the highest risk it believes in the principle that all

01:50:10 it believes in the principle that all residents

01:50:11 residents including those with disabilities should have equality with regards to the right to evacuate a building in the event of fire the Brigade has long advocated the benefits

01:50:24 Brigade has long advocated the benefits of an of an approach that properly considers

01:50:28 considers the individual characteristics behaviors and capabilities of residents that may be at higher risk from fire in their own accommodation and the LFC supports the

01:50:40 accommodation and the LFC supports the principle behind the government's proposals for emergency evacuation information information sharing but that's as far as that goes but but information sharing should not on the

01:50:53 information sharing should not on the commissioner's view on The lfb's View be considered a substitute for a plan in place to support residents to evacuate before the arrival of the

01:51:04 to evacuate before the arrival of the firearm Rescue Services and that's the key thing which we've done quickly and before the arrival of the fire and Rescue Services it's the duty of the responsible person for any building to give effect to to adequate procedures

01:51:16 give effect to to adequate procedures for all residents in case of fire it should be clear the wear evacuation of residence is concerned either to a place of relative safety or within the bill within the

01:51:28 safety or within the bill within the building itself or external to the building that should commence at the earliest possible stage and the LFC and the Brigade itself firmly believes that new buildings should be designed and

01:51:41 new buildings should be designed and built to be safe and fully consider the needs of those with disabilities not just those with mobility issues to ensure that buildings are designed to

01:51:53 to ensure that buildings are designed to be inclusive from the outset uh well so in in conclusion then over the course of more than four years this inquiry has conducted the most

01:52:05 this inquiry has conducted the most extensive

01:52:06 extensive forensic and forensic examination of the events of a major fire and its causes ever undertaken in the United Kingdom and most likely worldwide

01:52:18 and most likely worldwide that reflects the scale of the tragedy the breadth and complexity of its causes and the depth of the inquiry's commitment your commitment

01:52:31 your commitment as a panel and that of your team to ensure which you have demonstrated so robustly over the last few years to ensure that meaningful changes are

01:52:43 ensure that meaningful changes are implemented and sustained so that a tragedy tragedy such as grenful never happens again and that much at least is owed of course to those who lost their lives and to

01:52:54 to those who lost their lives and to those who survived and have suffered so much

01:52:58 much as well as to the wider public the London Fire commissioner reiterates the strong commitment of the Brigade as a whole to use this terrible tragedy

01:53:09 a whole to use this terrible tragedy as an opportunity to honor the bereaved and those who lost their lives by creating a legacy of positive change for the future

01:53:20 this is not only a time in his view to reframe the brigade's relationship with London but also to embrace criticism and learn from it so those are my final submissions thank

01:53:33 so those are my final submissions thank you very much well thank you very much indeed Mr Walsh

01:53:38 well that brings us to the end of our proceedings for today so we from Rise now but we shall sit again tomorrow morning at 10 o'clock

01:53:49 tomorrow morning at 10 o'clock when we shall hear closing statements from other core participants thank you very much 10 o'clock tomorrow then please