Phase 2 Overarching and Module 7 Closing Statements - Thursday 10th November 2022 (1/2)

Full transcript

00:21:01 foreign

00:21:05 good morning everyone welcome to today's hearing today we're going to hear overarching closing statements from two more of the core participants before we

00:21:16 more of the core participants before we hear the final statement from Council to the inquiry the first statement we're going to hear is going to be made by Mr Sean Branigan King's Council

00:21:27 Sean Branigan King's Council who has agreed to I think would be fair to say to stand in at the last minute for Mr Michael Douglas King's Council who we've heard from before on behalf of

00:21:39 who we've heard from before on behalf of X over but unfortunately is not well enough to attend today so Mr Branigan when you're ready please come up to the desk and we'll hear what you wish to say to us

00:21:55 members of the inquiry as you've just indicated I appear on behalf of xova instead of Mr Douglas he thanks the tribe general for their kind wishes and we are grateful for the

00:22:07 kind wishes and we are grateful for the time you have afforded to us to allow me to step in as you're also aware a number of the other core participants have elected not to make oral closing submissions

00:22:19 make oral closing submissions we have decided to take a different course

00:22:23 course uh xova have always taken the view that full uncommitted participation in this process is essential and that's really for two reasons

00:22:34 and that's really for two reasons the first is that such participation is essential in order to both honor and respect those who have been affected by the tragedy at grenfell

00:22:47 the tragedy at grenfell the second is that we have always seen it as part of our role to assist where we can to try and work out what I would describe as the center of gravity of causation

00:22:59 as the center of gravity of causation around which this tragedy occurred as a result I rise today to try and assist with some limited further submissions as you have just said German it's the

00:23:11 as you have just said German it's the first time I personally have made submissions to this inquiry and it is of course the last time that my client will it is therefore right and appropriate that I start as Mr Douglas started with

00:23:23 that I start as Mr Douglas started with his opening submissions many months ago to pay tributable to those who died in the tragedy and tribute also to those who have been left

00:23:34 left dealing with the effects of it that tribute is one that is easy to give on behalf of X over and its team because those who have been left have

00:23:45 because those who have been left have dealt with this tragedy in a way which is dignified Brave and human and for what our views are worth we can only command them for that

00:23:57 only command them for that I will not repeat the submissions we made in writing I don't think that would be helpful and it's clear that the panel will read them rather I will seek to do two things in the 30 minutes or so that I have this

00:24:09 the 30 minutes or so that I have this morning

00:24:10 morning uh firstly I want to explore with the inquiry this morning the conduct of the parties

00:24:16 parties that has overall been the most significant in terms of culpability causation of injury and loss of life and of course long-term loss of trust and confidence in the construction and

00:24:27 and confidence in the construction and Regulatory system and secondly I want to pick up towards the end of these short submissions a couple of other points of detail that arise from the overarching submissions made by the other parties

00:24:40 made by the other parties in the course of doing so of course I will seek to respond to points that have been made about X over I do so with humility recognizing that there might be an

00:24:52 recognizing that there might be an element of people saying well of course they would say that but as I say Xavier from the start has taken the view that everybody needs to do their part in the bits they know most

00:25:03 do their part in the bits they know most about

00:25:05 about to try and establish the real reality of what happened here in order to do our best to ensure this does not happen again so turning then to the first of the

00:25:16 so turning then to the first of the issues the conduct of the parties which has been the most significant the inquiry will no doubt have its own views as to how to approach that very difficult and multi-layered question

00:25:28 difficult and multi-layered question my suggestion is that a helpful approach if only in concert with other approaches is to First seek to identify the key decisions which led to the disaster

00:25:40 decisions which led to the disaster and having identified those key decisions

00:25:43 decisions turn to consider the fundamental factors which led to those decisions being made that first step identifying the key decisions we respectfully suggest

00:25:54 decisions we respectfully suggest is significantly easier now the evidence has been heard than it was whenever the inquiry started I respectfully suggest it's now clear

00:26:05 I respectfully suggest it's now clear that of all the decisions which led to the Grandville disaster and there were many

00:26:10 many there are two which are absolutely critical

00:26:15 critical the first is the decision to use render Bond

00:26:18 Bond acmpe as the cladding material on the exterior of the tar and the second and related decision was to use that material to form the architectural crown

00:26:30 architectural crown which ran around the top of the building we say that standing back and looking at it really for two reasons the first is the horrifying visual images of the Blazing tower on the night of 14th June

00:26:42 Blazing tower on the night of 14th June 2017

00:26:45 2017 and of course we now have as a result of the work done by the inquiry the experiments conducted at Edinburgh University under the supervision of professors Bisby on Torero

00:26:57 professors Bisby on Torero and we respectfully suggest that it is clear from both that the use of the acmpe it's in and of itself and in addition the use of that

00:27:08 itself and in addition the use of that within the crime was the source and cause of a fire which was otherwise unlikely to have spread and anywhere near the same way it may be the inquiry concludes that but

00:27:21 it may be the inquiry concludes that but for those two fearful decisions the fire which occurred would have been contained to a single flat or a single corner of the building

00:27:32 those two linked decisions were in turn made as a result of factors which I now turn to and which I do not shirk from saying we're indefensible

00:27:44 we're indefensible the first and most important factor was that this ACM material was not only available but promoted in the marketplace despite it being known to those who made and promoted its use to be a severe risk

00:27:57 and promoted its use to be a severe risk to life

00:27:59 to life we do not say known to be likely

00:28:04 likely we use those words because it is now clear from the evidence you have heard that during the development and production of that ACM material critical safety tests and classification

00:28:16 critical safety tests and classification results were concealed were manipulated and were misrepresented and that those things happen to the extent that the use of the material in

00:28:27 extent that the use of the material in high-rise residential buildings over the years became relatively commonplace

00:28:33 that concealment manipulation and misrepresentation we would suggest is a profoundly shocking and Central causative factor in this case

00:28:45 causative factor in this case and clearly a central cause of the factor that led to both of the key decisions I have just outlined

00:28:53 equally shocking of course was the malpractice engaged in by cell attacks and kingspan in the development testing promotion and sale of sellotex rs-5000

00:29:04 promotion and sale of sellotex rs-5000 and kingspan k-15 and as the inquiry now knows whilst those products did not have the same causative effect in terms of fire spread

00:29:14 spread the toxic smoke which emerged from the fire

00:29:18 fire was those two products was a key component Within

00:29:24 the second and important factor which led to the two decisions I have outlined been made

00:29:30 been made was the prioritization of cost over virtually any other Factor including very many of the factors that

00:29:41 including very many of the factors that a number of the other core parties have mentioned on behalf of residents because acmpe compared to other materials was cheaper with Jamaican to

00:29:52 materials was cheaper with Jamaican to buy it created Temptations which spread Beyond manufacturers the prioritization to cut costs Lord rbkc TMO to move away from the more

00:30:04 rbkc TMO to move away from the more expensive zinc cladding system that it appears it had been contemplating and towards using such acmpe more than that it led them to procure that new and

00:30:16 it led them to procure that new and different system in an illicit and secret process which was contrary to legal advice which circumvented proper procurement practice and which standing back can only have

00:30:29 and which standing back can only have made it more likely that those highly technical decisions I've just referred to would would ever receive proper technical scrutiny it made it much more unlikely

00:30:41 made it much more unlikely stepping aside from orbe KC TMO and towards writing exactly the same factors of cost Above All Else

00:30:49 All Else LED Ryden to promote that move to ACM as a method of recruiting money which would otherwise have been lost due to estimation errors when it put in its price

00:31:01 moving away from them it led the remaining technical team who were aware of the sudden introduction of acmpe to cut Corners in terms of proper technical scrutiny

00:31:14 scrutiny from the perspective of xova and understanding its role in the process the most obvious example of that to us and the example we can obviously most help with

00:31:26 help with is the decision of both rbkc TMO Ryden and all the members of the technical team

00:31:34 team to not involve a fire consultant in those decisions at all whether my client or any other fire consultant

00:31:46 consultant the inquiry May well think when it sits down to review all the evidence that that is remarkable given the nature of the change that was being made to cut costs

00:32:01 we say that because we believe and suggest that the following three things are Undisputed on the evidence a that there was a deliberate decision by Ryden not to appoint a fire engineer

00:32:14 by Ryden not to appoint a fire engineer whether it's over anyone else to the design team post-contract at B

00:32:22 at B apart from two or three ad hoc emailed queries on very specific issues about which you've heard evidence no fire consultancy advice was thought would sort from any other consultant so

00:32:34 would sort from any other consultant so it wasn't even a matter of not appointing one the amount of interaction That Was Then sought on an ad hoc basis from any fire consultancy expertise was limited in ad

00:32:45 consultancy expertise was limited in ad hoc

00:32:47 hoc and it appears to have been left to Studio e to deal with all fire-based regulatory matters and of course C studio is contract with Ryden was not

00:33:00 studio is contract with Ryden was not finalized until near the end of the contractual period with the result it appears that studio E's view of their contractual obligations differed materially from

00:33:11 obligations differed materially from Riders

00:33:13 Riders you may think whenever you are considering and weighing up the evidence

00:33:19 that if it is correct that both parties view of what studio he was going to do was materially different that can only be because of a lack of

00:33:32 that can only be because of a lack of management and a lack of prioritizing safety over cost which would have led to all of those things being sorted out earlier so we say the key decisions then are a

00:33:44 so we say the key decisions then are a result of four things arising from those factors

00:33:47 factors a a framework of Regulation and guidance that is damn Judith Hackett has said was not fit for purpose nor fixed when those were oversawed knew that to be the case

00:33:59 were oversawed knew that to be the case B manufacturers who knew and exploited the weakness in that framework C decision makers who cut Corners to cut costs and cover up their mistakes

00:34:11 costs and cover up their mistakes and D participants who failed to recognize the limits of their expertise combined with management who failed to Grapple with that fundamental problem

00:34:22 Grapple with that fundamental problem those conclusions are easy to see it of course

00:34:25 course now we have seen the evidence not so easy before this inquiry started but we say they arise from any structured approach to trying to review the evidence

00:34:36 the evidence going back in each case to the position of each participant when they first became involved going step by step through their actions looking at the circumstances as they were at that time and what information

00:34:48 were at that time and what information they had

00:34:50 they had asking where in the sequence of events did a particular participant make any decision or do any work and a Reliance on what information and so on then setting that picture against the

00:35:01 then setting that picture against the Matrix of contractual terms regulations guidance prevailing practices and so forth

00:35:07 forth and then on the basis of that stepping back and saying of all the failures of everybody involved in this project what really were the key things that ended up with those key decisions being made

00:35:18 with those key decisions being made [Applause] in a way so far one would suspect so uncontroversial but it's against that background that I have to turn then to the suggested

00:35:30 have to turn then to the suggested ranking of responsibility amongst the different participants which has been put forward in some of the overarching submissions you've heard and a particular I turn to the suggestion recently mirrored

00:35:42 suggestion recently mirrored that

00:35:43 that specifically in relation to the reason to use ACM it's over my clients should be regarded in a has been put in a primary group of responsibility alone iconic and

00:35:55 of responsibility alone iconic and Studio e ahead of a secondary group of those who actually made the decision to use this

00:36:01 use this which is ride in KCT Harley building control in others we respectfully disagree and indeed express some surprise at that ranking

00:36:13 express some surprise at that ranking we suggest that whenever one stands back and look us at the history I have just outlined that cannot be correct it cannot be protect correct in particular that Observer who was not part of the

00:36:25 that Observer who was not part of the post-contract design team and who nobody at the time regarded as being as part of that team

00:36:31 that team and who nobody at the time told that these decisions either were being made or had been made should be locked together in lists with those of who share all those

00:36:42 those of who share all those characteristics uh and we expressed some concern that any such lumping together doesn't properly place what I have described as the center of gravity

00:36:56 so in short then xova was not responsible our party to any of the key decisions which are made at the time xova provided his draft reports but there was no intention to

00:37:08 reports but there was no intention to use acmpe we say that emerges quite clearly from the evidence

00:37:14 when RB Casey TMO and Ryden decided to prioritize cost by selecting acmpe and then deciding to use it to form a crown at the top of the building

00:37:25 crown at the top of the building they did not ask exilver about that and xover did not advise them on that no more than that exother were not even told

00:37:35 so that's the decision making and in terms of the factors which I have sought to identify which led to that decision making

00:37:44 making eggs over had no part at all in the detailed design of the facade and vitally

00:37:50 vitally exilver had no part at all in the promotion of two either TMO or the market as a whole of acmpe it's over had literally nothing to do

00:38:01 it's over had literally nothing to do with any of that equally it had literally ain't nothing to do

00:38:06 to do in the decision by those who are doing the construction to prioritize cost over other factors the saving of course formed no part of its role it was not asked to advise and

00:38:18 its role it was not asked to advise and say on cost savings it did not advise on cost savings it was not invited to the secret meeting by which Ryden secured his appointment on the base of cost reductions it played

00:38:29 on the base of cost reductions it played no part in the failure by rbk say TMO and Ryden to follow the Change Control procedure required by rydon's contract and approving the switch to acmpe

00:38:41 and approving the switch to acmpe and I played no part in the management of now of those cost-saving measures and in particular the failure to establish who was responsible for dealing with building regulations and who was going to Grapple with that

00:38:54 and who was going to Grapple with that it had no part in any of that and we can see that from the timeline again we suggest the evidence is clear over the period from the end of October

00:39:05 over the period from the end of October 12 until the end of the refurbishment exover was invited to a total of two meetings with building control they happened in November 12 and September 2013.

00:39:17 September 2013. it was invited to no meetings at all after writing's involvement and no meetings at all after the choice of building materials no one at the time took the view that Xavier playing any role which meant that

00:39:30 Xavier playing any role which meant that it should be so invited there was no suggestion that in any meeting anybody turned around and said hold on where is X over nobody thought they should be there

00:39:43 nobody thought they should be there even before ryden's appointment though all the other parties received Studio e stage d report in August 2013 it was not provided to Observer again that was not an accidental

00:39:55 again that was not an accidental Omission it was not presented or provided to xover because nobody thought it appears that Xavier should have it the NBS formed a key element of the

00:40:06 the NBS formed a key element of the employer's requirements for the tendering process it was provided to all the prospective contractors and was the basis for their bids

00:40:14 bids but it was never provided to Observer either for comment or information again that was not accidental nobody ended up saying how did we miss the email sending it to X over

00:40:25 email sending it to X over it was not sent because nobody thought exilver had any business having it every single one of the other parties involved in the project was aware of the decision to use ACM PE

00:40:37 decision to use ACM PE at grenful tar the TMO Harley and Ryden expressly pushed for its use TMO Studio e Harley and Ryden were directly responsible for a selection and

00:40:49 directly responsible for a selection and rbkc approved its use like silver didn't even know it was happening

00:40:55 happening once Ryden was appointed its first step was to formalize the switch to ACM were upon it instructed the design team I will just talk in a second what that means

00:41:06 means to start work but none of the other parties thought that Observer was part of that design team nor relied on exorbitant determining the decisions or behavior

00:41:22 it is important against that background to note that although some of the other participants in their submissions now make suggestions to the contrary none of those submissions is based on

00:41:33 none of those submissions is based on the evidence of any of the witnesses who worked with xova on the project are any of the contemporaneous communications say for one exception that one exception is Mr Crawford of

00:41:44 that one exception is Mr Crawford of Studio e

00:41:46 Studio e who in his oral evidence though not as written evidence suddenly recalled a conversation with Mr Ashton

00:41:54 Ashton you have heard evidence on that and you will have you will either have taken a view or you will and do a course take a view as to whether or not that conversation happened Mr Ashton said it did not

00:42:05 Mr Ashton said it did not and we respectfully suggest that in the circumstances in which that suggestion was suddenly made orally in evidence without any supporting documentation

00:42:16 without any supporting documentation that evidence should be accepted

00:42:19 rather the submissions and closing by other participants that Observer should be regarded as towards the front of the

00:42:30 regarded as towards the front of the line if I may put it in that colloquial way in terms of what happened is based on Dr Lane's report now in module one and oral submissions exover was critical

00:42:42 and oral submissions exover was critical of Dr Leon's evidence and a lot of those criticisms about her stage one report remain

00:42:49 remain but more importantly than our criticisms is this

00:42:52 is this the inquiry may think it's really quite important to note that Dr Leon's issue two reports under oral evidence led to a significant reduction

00:43:03 significant reduction in the both the ex the nature of the criticisms on the extents and if I may put it this way the ferocity of the criticisms that were being made against exilver

00:43:14 exilver that is not an accident it reflects we respectfully suggest the the evidence which emerged between um the two reports the important

00:43:26 the important um Wares in which her evidence has moved on

00:43:30 on we say can be found and of course you're not going to turn it up now but I'll give the reference at Pages 9 to 20 of the transcript for day one seven four on the 14th September 2021

00:43:42 on the 14th September 2021 the inquiry will of course reread that transcript but the passage I've just cited we respectfully suggest is really quite important from the perspective of dealing with the issue that I seek to

00:43:53 dealing with the issue that I seek to try and help with were the center of gravity lies in terms of what happened in summary in the passage of the report we that were set out of that bit of the

00:44:04 were set out of that bit of the transcript Dr Leon conceded first the importance of the change of cladding material to acmp as I've just discussed and the importance of the fact that xova was not

00:44:15 importance of the fact that xova was not informed or consulted about it she by that stage and my respectful submission had come to recognize that that is a quite an important factor secondly and importantly Dr Lane said

00:44:28 secondly and importantly Dr Lane said she could understand why before 18 September 2014 exilver may not have read or proactively sought relevant information about the external wall buildup

00:44:39 buildup which upon which to basis fire strategy and thirdly this was then expanded in our oral evidence to acknowledge the very limited practice among competent members of the fire profession before grenful in

00:44:53 fire profession before grenful in relation to the checking of materials

00:44:56 on analysis since acknowledging that Observer was unaware of the proposed use of ACM Dr Lynn nowhere and her reporter or oral evidence expressly or implicitly

00:45:08 evidence expressly or implicitly criticizes Mr Ashton for not having noted or advised in the proposed use of ACM I'm going to turn to sell attacks in a second but I underline ACM there

00:45:19 a second but I underline ACM there and I respectfully submit that the submission I've just made is plainly correct when you come to look at her evidence

00:45:25 evidence rather her criticism now appears to turn on two suggestions first two that is over field in quotes not writing down the recommendations or requirements of adb2 close quotes

00:45:38 requirements of adb2 close quotes and secondly an alleged failure to deal with the fact that cell attacks was not a material of limited combustibility after the 18th of September 2014.

00:45:50 after the 18th of September 2014. the inquiry we have no doubt will consider those criticisms carefully certainly we take them very seriously and we say the following first neither of those criticisms even

00:46:02 first neither of those criticisms even if made out could possibly justify the conclusion that despite not even knowing it was happening and forming no part of the decision-making process exover was

00:46:13 the decision-making process exover was one of the main reasons why acmpe came to be used but secondly we respectfully suggest the tribunal will have to be careful about the way it puts in either criticism

00:46:25 the way it puts in either criticism concentrating on the second criticism about cell attacks the the following four points are important a as I say a paragraph

00:46:36 a as I say a paragraph 9.4.41 of her report Dr Leon says she can understand why before 18 September 2014 it could be said that Xavier may not have read or

00:46:47 said that Xavier may not have read or proactively sought relevant information about the external wall B the importance of that data appears to be the email exchanges on that day of

00:46:58 be the email exchanges on that day of the 18th of September in which in an email exorba was asked to provide ad hoc advice and a seller Text data sheet was included as an attachment

00:47:11 data sheet was included as an attachment uh C

00:47:13 uh C reading Dr Lynn's evidence carefully it appears clear that her criticism proceeds on the premise that Mr Ashton opened and read that data sheet and therefore should have acted on the

00:47:25 and therefore should have acted on the material he saw there but D and we say this is quite important the inquiry will need the effort to understand whether that assumption that

00:47:36 understand whether that assumption that Mr Ashton read opened and read the data sheet is right or not it can only be an assumption because obviously Dr Lane doesn't know but as to that there is no evidence that

00:47:48 but as to that there is no evidence that he did

00:47:49 he did no more than that the evidence is that he did not if one looks at the transcript at t17 page 46 lines 17 to 20 you will see that

00:48:00 page 46 lines 17 to 20 you will see that quite properly counsel for the inquiry put that precise point to him and he was entirely clear that he had not opened it and read it

00:48:11 not opened it and read it there is no reason at all to to disbelieve that evidence leaving aside the fact that we respectfully suggest he was an honest Witness

00:48:20 Witness the facts surrounding that email exchange support what he said firstly he's not asked in the relevant email to read or repine on the data sheet it is appended on mentioned

00:48:32 sheet it is appended on mentioned secondly it appears to be common ground on a I submit it should be if not that the data sheet was irrelevant to the question he was asked and thirdly there was nothing in his answer by email to

00:48:45 was nothing in his answer by email to indicate that he had nonetheless looked at the data sheet you members of the inquiry are as well placed as Dr Lane to work out whether in fact the Assumption of that underlying

00:48:58 fact the Assumption of that underlying her criticism of him is correct as a matter of fact and resubmit it isn't uh that is vitally important because by 18 September 2014 all the

00:49:10 because by 18 September 2014 all the other parties dealing with the design and exterior of Grandfather were a were had been a change to the design incorporating the Rainer Bond acmpe and sellotex rs-5000

00:49:21 sellotex rs-5000 there was now a subtle scheme on the basis of which eggs over could for the first time have been asked to advise on drawings plans or specifications but none of the other parties start to

00:49:32 but none of the other parties start to inform X over of the changes now ask Xavier to comment that would have been the simple professional and the only competent way of dealing with another professional if

00:49:44 of dealing with another professional if their view was sought or a further report was wanted Mr Suns you will recall acknowledge that a further report would have required a further instruction and that surely must

00:49:55 further instruction and that surely must be right

00:49:56 be right against that background to try and suggest that Observer is at the Forefront of blame because it's not uncover Clues and an unnamed and unmentioned document which was related to an ad hoc question that could be and

00:50:07 to an ad hoc question that could be and was answered in his own terms is we would suggest not helpful it doesn't accurately place the center of gravity I'm conscious of the time and I have about two minutes left if that's okay

00:50:18 about two minutes left if that's okay with the inquiry

00:50:22 lastly in this section I should deal with uh the criticisms which are made and the number of submissions about paragraph 3.1.4 of the ofss

00:50:33 paragraph 3.1.4 of the ofss We have dealt with in some detail with what we say that language means and how it should be construed for the purpose of this closing I would just highlight one further point

00:50:45 just highlight one further point there is no evidence at all by any of the other parties of any Reliance at the time upon the statement which is now criticized that we say is important in a situation

00:50:58 that we say is important in a situation where none of the other participants have been slow to point the finger elsewhere and to come up with justifications for their conduct

00:51:09 if the other participants had relied upon anyway in the wording the ofss they would have said so none of them have done again if we are to understand as a

00:51:22 again if we are to understand as a grouper as an inquiry the truth of what happened that cannot in my respectful submission be ignored uh three further points if I may uh and I come on to the second part of my

00:51:33 I come on to the second part of my submissions where I said I deal very briefly with them uh

00:51:38 uh firstly it's been suggested not Dr Lane criticized Mr Ashton for not picking up a reference to rain screen aluminum cassettes in March 2015 correspondence

00:51:49 correspondence in my respectful submission that overlooks a part and part of the transcript day 62 Pages 63 to 64. in which Dr Lane made very clear my resubmission

00:52:01 resubmission um the extent of her criticism in that regard and I respectfully suggest that the other parties have sought to stretch her criticism Beyond where it should go

00:52:13 criticism Beyond where it should go secondly

00:52:17 uh a point where I don't play a number of other core participants is that Dr Lee and her report has argued that despite not being appointed by Ryden he's over continued to be engaged as a fire engineer by Casey TMO

00:52:31 fire engineer by Casey TMO and Ryden goes as far as to suggest that therefore its decision not to appoint the made no difference we respectfully suggest that that is simply not correct

00:52:43 simply not correct and we point to really two points firstly

00:52:48 firstly kctmo did not believe that xorva continued as their fire engineer in their written opening their list takes over as part of the design team pre-appointment of Ryden but not afterwards

00:52:59 afterwards that again must be important if neither KCT nor Amo Amo noros thought that xova was appointed by kctmo that cannot be

00:53:10 was appointed by kctmo that cannot be ignored

00:53:12 ignored so many ryden's witnesses are clear about the parties for whom they relied and that did not exclude include exilver until we strongly suggest

00:53:24 until we strongly suggest that a key point is Mrs Williams of tmo's Lock and L moment that was a clique a a cleaving point in terms of when this position could

00:53:37 in terms of when this position could have been saved by somebody recognizing that there could be a significant problem and on behalf of X over I respectfully suggest the inquiry May well think that was a very important indeed missed

00:53:49 was a very important indeed missed opportunity but who did she turn to when she had her lock and L moment to to give her comfort and to deal with it it wasn't Xavier it was to Ryden and I tell you

00:54:01 was to Ryden and I tell you whenever she turned to them who did they turn to nothing's over no one did

00:54:08 uh thirdly and finally in the time available to me Professor Torero's advocacy report certainly weird eggs over think that what Professor torreiro is has done is

00:54:19 what Professor torreiro is has done is really very valuable and we don't seek in any way with these submissions to undermine that at all but we do respectfully suggest that it is being misconstrued

00:54:31 is being misconstrued as we read Professor torreira's report in this regard it is a forward-looking not backwards looking document it is an attempt to say what best practice should be now

00:54:42 practice should be now not an attempt to say that everybody who did not follow that practice in the past was by definition and because of that negligent

00:54:52 negligent and we do suggest that a slight element of opportunism on behalf of other participants seeking to shift the center of gravity away from them

00:55:01 them to interpret what he has said as a criticism of the past as opposed to a blueprint for how we might work forward in the future

00:55:11 [Applause] the thrust of these submissions as I finished was this the detailed history who was actually involved in the key decisions and it was actually instrumental on the factors

00:55:23 actually instrumental on the factors which led to those decisions including the history of who was involved in them and who was excluded is important because it is only from that that one

00:55:34 because it is only from that that one can take the lessons as to what happened and only from that that this inquiry can make recommendations as to how we as a society can make sure that the tragedy of grand foot does not happen again

00:55:47 of grand foot does not happen again misplacing the center of gravity it doesn't help anybody those are my submissions thank you very much indeed uh finally we're going to hear from uh

00:56:01 uh finally we're going to hear from uh Mr Jason beer King's Council on behalf of the department for leveling up housing and communities

00:56:21 as you said this statement is made on behalf of the Department of leveling up housing in communities following the conclusion of all of the evidence to be heard by this inquiry as before I'll

00:56:33 heard by this inquiry as before I'll refer to the department as the department the department is aware that in its letter of the 10th of June of this year the inquiry indicated that it wouldn't be assisted by the repetition of

00:56:46 be assisted by the repetition of submissions already made in the closing statements for each of the modules and therefore the department takes this opportunity to set out some very brief closing remarks which it hopes will

00:56:57 closing remarks which it hopes will assist the inquiry firstly and most importantly the department wishes to take this opportunity to record again its sincere sympathies for those who have been so

00:57:08 sympathies for those who have been so terribly affected by the events of the night of the 14th of June 2017. the bereaved survivors and residents groups have been a model of dignified involvement throughout your inquiry

00:57:21 involvement throughout your inquiry secondly the department wishes again to apologize for its failure to ensure effective whole system oversight of the Regulatory and compliance regime

00:57:33 Regulatory and compliance regime the department recognizes that it failed to appreciate that it held an important stewardship role over the regime and that as a result it failed to grasp the

00:57:45 that as a result it failed to grasp the opportunities to assess whether the system was working as intended for the Department's failure to realize that the regulatory region system was

00:57:56 that the regulatory region system was broken

00:57:57 broken and it might lead to a catastrophe such as this the department is truly sorry and apologizes unreservedly thirdly the department wishes to

00:58:09 thirdly the department wishes to emphasize its commitment to driving change to ensure that a tragedy is never permitted to happen again and to emphasize the work already done

00:58:20 and to emphasize the work already done to this end that this department has engaged with this independent inquiry since it was established to make sure that all of the right lessons are learned but it has not

00:58:32 right lessons are learned but it has not stood by idly in the meantime the fire safety act 2021 and the building safety act 2022 bring about lasting changes to overhaul a regulatory

00:58:44 lasting changes to overhaul a regulatory system that has been shown to have been unfit for purpose the department has submitted a comprehensive statement to you on reforms and looks forward to engaging

00:58:56 reforms and looks forward to engaging with the inquiry to assure ensure that any additional areas of concern are addressed

00:59:02 addressed where further change is necessary the department is committed to implementing it

00:59:08 it the department very much looked forward to receiving the inquiry's recommendations

00:59:14 finally the department invites the inquiry to note its ongoing commitment to support the work of the inquiry the department has engaged throughout phases one and two fully

00:59:26 one and two fully frankly and openly and it shares the inquiry's aim of getting to the truth of what went wrong to prevent it from happening again whilst the Department's commitment to

00:59:37 whilst the Department's commitment to support the inquiry and its recognition of its own failings cannot change the tragic events of the 14th of June 2017 nor in any way compensate for the immeasurable loss and

00:59:50 compensate for the immeasurable loss and grief and suffering of the bereaved survivors and residents the department hopes that its sincere commitment to ensuring that such a catastrophe cannot happen again give some small measure of

01:00:02 happen again give some small measure of comfort to all of those affected so that's all I say thank you very much Mr Bill well in a moment we're going to hear some closing remarks from Council to the

01:00:15 some closing remarks from Council to the inquiry who Mr Richard Millett King's council is necessary to have a break before we do that and I think rather than interrupt what Mr Miller wants to say the sensible course would be to take

01:00:27 say the sensible course would be to take the morning break much earlier and phrase than usual but that will as I say give Mr Millet the opportunity to make his remarks without interruption so we'll rise now we'll resume at 5 to 11.

01:00:40 we'll resume at 5 to 11. and uh then hear what Mr minute has to say so 5 to 11 please thank you thank you

01:17:28 foreign

01:17:32 statement by Mr minute Queen Kings Council on as canceled the inquiry yes Mr Miller Mr chairman members of the panel before I

01:17:43 panel before I start my closing statement in this inquiry I should just read into the record by way of housekeeping a reference for 10 witness statements

01:17:54 reference for 10 witness statements which now need to be read in and that is to be found under the reference idx0965

01:18:04 at 12 54 29.

01:18:08 29. on the 14th of June 2017 Mr bahelu kabidi made the first of what was to be a torrent of 999 calls to the lfb's

01:18:19 a torrent of 999 calls to the lfb's control room at Stratford informing the lfb of a fire in the kitchen of his flat flat 16 on the fourth floor of grenfell Tower

01:18:31 fourth floor of grenfell Tower in Phase One of this inquiry we learned what ensued then over the following minutes and hours of that summer night in West London in which 71 residents of

01:18:42 in West London in which 71 residents of the building lost their lives and a further life was lost after the principal question for phase two is why did that happen

01:18:54 why did that happen to answer that we have to understand the world as it had come to be as at 12 54 29 on the 14th of June 2017 and to

01:19:06 29 on the 14th of June 2017 and to understand how it had come to be that way

01:19:08 way what was the wider context for the lfb's preparedness being as it was at that moment for the building being refurbished as it had come to be for the

01:19:20 refurbished as it had come to be for the fire management arrangements for those who lived in it being as they were for the building regulations being as they were for the cladding and Construction Industries being as they were

01:19:33 Industries being as they were and for Central government's state of knowledge about all of those matters and what indeed was the state of Machinery of government when it came to understanding and

01:19:44 when it came to understanding and regulating fire risk particularly in tall buildings from all of the evidence that you have heard at phase two you are able to distill a single overall conclusion that

01:19:58 distill a single overall conclusion that there was nothing unknown or not reasonably knowable which caused or contributed to the fire and its consequences on the contrary each and every one of

01:20:09 on the contrary each and every one of the risks which eventuated at grenfell Tower on that night were well known by many and ought to have been known by all who had any part to play as a result you will be able to conclude

01:20:21 as a result you will be able to conclude with confidence that each and every one of the deaths that occurred in grenfell tower on the 14th of June 2017 was avoidable

01:20:33 was avoidable the reasons were many complex and in many cases inextricably interlinked some had an immediately causative effect and others less so

01:20:46 and others less so it is open to you on the evidence to conclude that there was a long run-up of incompetence and poor practices in the construction industry and the fire engineering at Architects

01:20:58 and the fire engineering at Architects profession weak and incompetent building control cynical and possibly even dishonest practices in the cladding and insulation materials manufacturing sector

01:21:10 materials manufacturing sector incompetence weakness and malpractice by those responsible for testing and certifying those materials the failure of central government to act despite known risks failures of competence training and

01:21:23 failures of competence training and oversight

01:21:24 oversight within the TMO and over it by rbkc a failure by the lfb to learn the lessons of lacknell and are the fires

01:21:35 lessons of lacknell and are the fires and to train its operational staff to collect understand and to act on the risks presented by modern construction methods and materials risks well known to some but not all

01:21:46 risks well known to some but not all within that Institution and behind all of these discrete factors delay complex opaque and piecemeal legislation

01:21:57 legislation and an over-reliance by law and policy makers on guidance some of which including the statutory guidance was ambiguous dangerously out of date and

01:22:08 ambiguous dangerously out of date and much of which was created by non-governmental bodies and influenced by commercial interests many of these conclusions themselves arise from admissions made in the in the

01:22:19 arise from admissions made in the in the course of

01:22:20 course of submission or in the course of evidence some of course remain highly contested there are certain common structural

01:22:31 there are certain common structural themes that persist across the evidence insufficient or inadequate standards of competence poor ill-focused or insufficient training lack of independent peer review

01:22:44 training lack of independent peer review inability or unwillingness to regulate conflicts of interest sufficiently robustly

01:22:50 robustly under resourcing short-termism siled thinking over dependence on small numbers of individuals with professed expertise

01:22:59 expertise lack of internal challenge systems over complicated strategies policies protocols governance structures that value the purity of conceptualism Over

01:23:10 value the purity of conceptualism Over The Human Experience localism various deregulatory policies pursued by successive governments a fundamental failure to understand and to assess fire risk in high-rise blocks

01:23:22 assess fire risk in high-rise blocks and a concomitant failure to pay due respect to the idea of home as a physical aspect of human privacy agency safety and dignity

01:23:37 agency safety and dignity now those are systemic and they are abstract ideas the fire the last moments of those who were trapped and doomed in and by that building and the death that

01:23:48 and by that building and the death that ensued were anything but it will therefore be crucial when you come to consider the evidence not to start with grand themes or preconceived narratives but to work from what lies on

01:23:59 narratives but to work from what lies on the ground in front of you the Myriad shards of evidence the emails notes minutes slides witness statements reports audits certificates which form

01:24:10 reports audits certificates which form the stories of how we got to grenfell and what should be done about it as a result

01:24:19 result the focus of my closing today is culpability and causation listening to the last three and a half days of overarching closing statements from a range of core participants

01:24:31 from a range of core participants if everything that has been said is correct

01:24:36 correct then nobody was to blame for the grenfell tower fire can that really be right is the answer that you are to give to the survivors to The Grieving families and to The Wider public

01:24:48 and to The Wider public to be that the grenfell tower fire was just a terrible accident just one of those unfortunate incidents have happened occasionally or is it to be that there are so many to blame that no one individual or

01:25:01 blame that no one individual or organization shoulders very much blame is that the answer that these core participants taken collectively would urge upon you and if they do are they really as sorry as they say

01:25:15 are they really as sorry as they say when I opened this inquiry as Council as Mr Adrian Williamson King's Council has now reminded you and others since I told you that all the indications were

01:25:26 I told you that all the indications were to be that some at least of the core participants would indulge in what I termed a merry-go-round of buck passing I had hoped that my task and so your

01:25:37 I had hoped that my task and so your task in turn would be made easier by candid admission of blame some core participants principally public bodies have made carefully expressed admissions of specific fault

01:25:51 expressed admissions of specific fault my metaphor may now have become rather worn particularly this week but for many even now on day 312 of this phase of this inquiry the Merry-Go-Round turns

01:26:04 of this inquiry the Merry-Go-Round turns still the notes of its Melody clearly audible in the last few days and if you listen closely to the tune you can begin to

01:26:17 closely to the tune you can begin to hear that many core participants have adopted a particular technique namely the deflection of criticism by reference to causative relevance and then in turn to take a narrow and

01:26:28 then in turn to take a narrow and Technical approach to causative relevance in order to escape blame for the fire and the ensuing deaths but then to blame others without any regard necessarily to causative impact

01:26:40 regard necessarily to causative impact one striking example and it is an example is celatex's position in admitting that the marketing literature for RS 5000 concealed the existence of the layer of magnesium oxide on the test

01:26:52 the layer of magnesium oxide on the test rig in describing the test components as it did but then to blame the Professionals in the design team for not reading the marketing leaflets in full in order to ensure that the system being

01:27:03 in order to ensure that the system being fitted at grenfell Tower would be identical to that tested so is sellotex blaming the Professionals for their failure to read celetex's misleading document

01:27:14 misleading document there are many other such examples across the range of core participants this kind of Casius tree which is what it is is not helpful to you in working out who is to blame

01:27:27 out who is to blame it is an enduring and a regrettable mark of that failure that throughout this inquiry

01:27:32 inquiry but with notable exceptions I must emphasize that those responsible for the building and the building environment being as it was on the night of the fire sought to exculpate themselves and to

01:27:44 sought to exculpate themselves and to pin the blame on others expressions of regret for the victims of the fire have been as common to the point of trite as admissions of responsibility have been rare a tragedy of these Dimensions

01:27:57 rare a tragedy of these Dimensions ought to have provoked a strong sense of public responsibility instead many not all many core participants appear simply to have used

01:28:08 participants appear simply to have used the inquiry as an opportunity to position themselves for any legal proceedings which might or might not follow in order to minimize their own exposure to Legal liability now quite apart from the lack of respect

01:28:20 now quite apart from the lack of respect that that stance shows to the victims and their families it makes your task all the harder a public inquiry is not the place for cleverness but for Candor

01:28:31 the place for cleverness but for Candor the public has a right to expect that those persons who are granted core participant status in public inquiries and take all the benefits of that status will in turn act in the public interest by making admissions against their own

01:28:43 by making admissions against their own private interests where the evidence clearly justifies it in the case of this inquiry that expectation has been largely disappointed at least until Witnesses

01:28:55 disappointed at least until Witnesses were confronted with the contemporaneous documents and very often not even then many questions were asked of many witnesses for hundreds of days one question remains who among the core

01:29:10 one question remains who among the core participants has actually admitted that they caused or contributed materially to these deaths

01:29:18 deaths that may be one question too many and too much to expect humankind cannot bear very much reality but in the absence of an answer the focus of my closing is to map out for

01:29:30 focus of my closing is to map out for you who blames whom and for what there are three reasons for doing that legal cultural and moral so far as legal is concerned section 2-1

01:29:42 so far as legal is concerned section 2-1 of the inquiries act 2005 expressly prohibits you from ruling on any person's life legal liability civil or Criminal

01:29:51 Criminal and you have no power to determine that liability that must remain a matter for the courts however section 2-2 expressly provides that you are not to be inhibited in the

01:30:02 that you are not to be inhibited in the discharge of your functions by any likelihood of liability being inferred from any facts that you find or recommendations that you make I would invite you to interpret that

01:30:13 I would invite you to interpret that broadly you can look at the basis on which responsibility is assumed whether it be in the terms of a contract or the way in which such contracts were normally understood and normally

01:30:24 normally understood and normally performed according to prevailing standards of the day or other forms of legal or customary relationship you are not precluded from concluding that persons were Bound by contractual

01:30:35 that persons were Bound by contractual or statutory or other legal obligations or voluntarily assumed them and that they failed to discharge them nor are you prohibited from reaching conclusions about the causative effects of such an

01:30:48 about the causative effects of such an act or a mission indeed this inquiry would be severely hampered in the discharge of its terms of reference were you not to be free to do that your approach to issues of causation should similarly be unconstrained by the

01:31:01 should similarly be unconstrained by the legal principles normally applicable under civil or criminal law you should not find it necessary to investigate for example whether events were original causes or concurrent

01:31:12 were original causes or concurrent causes or but for causes the question is whether a particular fact or event or decision as you find on the evidence had a material bearing on the events in grenfell tower on the

01:31:25 the events in grenfell tower on the night of the fire and if so to what extent and in what wider circumstances as to that there's a spectrum some events had an obviously causative

01:31:36 some events had an obviously causative potency some events had a much clearly less clearly causative role some events serve to influence the culture in the industry or Industries and in turn the regulatory response to

01:31:49 and in turn the regulatory response to that culture although it would be unwise and likely impossible to seek to attribute any single originating cause to this tragedy or to devise any strict hierarchy of

01:32:00 or to devise any strict hierarchy of concurrent causes part of your task is to seek so far as the evidence permits to distribute responsibility among those involved

01:32:10 involved it would also be unwise and likely impossible to attempt to construct counterfactual situations positing speculative outcomes based on hypotheses that is because there are so many things

01:32:22 that is because there are so many things that happened so many decisions so many potential causes some in sequence some in parallel that the different combinations are potentially infinite instead you should seek to identify

01:32:34 instead you should seek to identify where on the evidence there were relevant missed opportunities which if taken might reasonably be supposed to have had a more than minimal effect on the outcome

01:32:47 the reason to investigate the Maze of parallel and competing causes is not only legal but cultural many of the failings of many of the organizations revealed by the fire and

01:32:59 organizations revealed by the fire and the evidence about it are redolent of a culture pervasive through these organizations of dissociation blame shifting and defensiveness to cover up incompetence lack of skill and

01:33:10 incompetence lack of skill and experience false and unverified assumptions and playing carelessness or lack of Engagement there will have been many times in the evidence when I don't doubt that you will have been struck by how many

01:33:22 will have been struck by how many witnesses thought that something was somebody else's job but never bothered to check and there's a moral Dimension to this approach too regret is not the repeated and mournful

01:33:35 regret is not the repeated and mournful use of the word sorry but the achievement of a practical outcome reflecting permanent self-corrective action the families of those who died and The Wider public want to know who is to

01:33:48 Wider public want to know who is to blame for this tragedy how culpability is shared

01:33:52 is shared and what will be done about it based on a close study and Analysis of the facts you can and you must help them answer that question it is only then that the Merry-Go-Round can stop and the families can start to get some kind of

01:34:05 families can start to get some kind of closure

01:34:06 closure now I'm now going to map out for you how many of the main co-participants seek to point to others to allocate blame in some cases I must stress you

01:34:18 blame in some cases I must stress you may well find that they are obviously Justified

01:34:21 Justified in some cases less obviously but nonetheless Justified and in some cases not justified at all I am not going to indicate to you today whether they are or not justified that must be for you

01:34:32 or not justified that must be for you my sole goal is to present and explain the main strands in the spider's web of blame in a neutral way can I please have the presentation up on

01:34:44 can I please have the presentation up on the screen please

01:34:50 start with our comic

01:34:55 and we start with iconic because iconic or AAP SAS made the ACM PE in the phase one report Mr chairman you

01:35:06 in the phase one report Mr chairman you identified that material and its presence on the building as the principal cause of the spread of the fire

01:35:14 fire conic for its part specifically identifies the following matters which it says are of causative relevance and we start on the night of the fire

01:35:25 we start on the night of the fire on the night of the fire so far as the exit of the fire into the cladding is concerned from Flat 16. that was caused that was not caused by the ACM but by first the use of combustible materials

01:35:37 first the use of combustible materials around the windows the design of the window sets which left gats and the use of combustible insulation now the combustible insulation says

01:35:48 now the combustible insulation says iconic played a part in the speed with which the fire started to impinge on the cladding once in the cladding it was the presence of a continuous surface of combustible insulation on the opposite

01:35:59 combustible insulation on the opposite side of the inner cavity that was to blame for the delamination of the aluminum skin and the total combustion of the polyethylene within it cavity barriers lack of suitable cavity

01:36:11 cavity barriers lack of suitable cavity barriers

01:36:12 barriers our colleague also blames the presence of Aloo glaze which it says was quotes analytically comparable unquote to acmpe the Disney contribution of the fire

01:36:24 the Disney contribution of the fire loads from the contents of individual residents Flats gets some of the blame as does the upvc window surrounds and the unorthodox fabrication of the panels

01:36:36 the unorthodox fabrication of the panels by cep

01:36:38 by cep iconic also blames the failure of others in the supply chain to make sure that the fabricated panels were suitable for use on grenfell Tower and compliant with the building regulations focusing particularly for the moment on

01:36:50 focusing particularly for the moment on combustible insulation iconic says three things essentially first that the panels were only there to protect the insulation from the rain

01:37:01 insulation from the rain Atlanta for the need for insulation there would have been no need for any rain screen second insulation was only there because of the government's green agenda and Builders could only achieve ever more

01:37:12 Builders could only achieve ever more thermally efficient wall buildups by using insulation that was not Material of limited combustibility and the use of combustible insulation in the Sudbury and taploid fires in which

01:37:24 the Sudbury and taploid fires in which involved non-combustible mineral wool insulation fire spread was contained so far as the use of the ACM was concerned

01:37:34 concerned the first ACM was in common use in the UK for years says iconic they say it was regarded as permitted above 18 meters not least because the surface of the exterior wall was not required to be

01:37:46 exterior wall was not required to be material of limited combustibility in that connection nobody thought they say that the word filler in approved document B section 12.7 extended to the core of a rain screen panel see for

01:37:58 core of a rain screen panel see for example the 2nd of July 2014 cwct meeting where that very matter was discussed

01:38:05 discussed iconic says that people misunderstood class not if they thought that they needn't consider the rest of the wall buildup class naught after all is a product test and not a system test and of course the UK government decided

01:38:18 and of course the UK government decided to retain class naught despite the fact that some products achieving it would not achieve Class B as UK government knew

01:38:26 knew coming to the BBA certificate for arena Bond 55pe there was nothing wrong with it says iconic says it was precise and accurate because the surface of an

01:38:38 accurate because the surface of an unfabricated panel could achieve and had achieved a Class B and that was all it was satisfying it wasn't it wasn't certifying the fixings it says the terms

01:38:50 certifying the fixings it says the terms orphe made it plain that you couldn't incorporate a aluminum composite material polyethylene called panel in a cladding system without conducting a holistic fire engineering assessment it

01:39:02 holistic fire engineering assessment it blames the design team for not reading the certificate and understanding that it seems to be part of iconic's case that Harley failed to stop themselves being misled about the class of panels

01:39:14 being misled about the class of panels stated in the certificate of which Harley complains by failing to investigate the difference in color the gray green as tested and stated as tested in the certificate as against the

01:39:26 tested in the certificate as against the smoke silver as installed at grenfell

01:39:31 before the fire and so far as others are concerned a little bit of which I've already covered iconic blames cep which preferred polyethylene to FR chord ACM

01:39:42 preferred polyethylene to FR chord ACM panels because it was easier to Mill and didn't cause damage to cutting tools it blames Ryden which they say it says should have checked especially after Claire Williams's lack and all moment email on the 12th of November 2014

01:39:55 email on the 12th of November 2014 for its part Studio he knew quote that quotes metal cladding always Burns and falls off because it was told so in March 2015. Harley knew the same and in any any case failed to read the BBA

01:40:06 any any case failed to read the BBA certificate properly or at all and all of them knew of but ignored the option of FR as a court stated as available by the BBA certificate X over promised but failed to deliver a

01:40:19 X over promised but failed to deliver a future analysis of the external wall construction and its compliance with functional requirement B4 and the kingspan of celotex are to blame for misleading the market about the safety and compliance of their

01:40:31 safety and compliance of their insulation products when used on tall buildings

01:40:34 buildings and that in turn a holistic fire engineering assessment was not required that is iconic's big but for argument on causation it was all Kings bands and celatex's fault

01:40:46 celatex's fault so far as the acmpe is concerned it was the BBA who drafted the certificate and decided what information they needed to include in it they never asked about

01:40:58 include in it they never asked about tests on cassette fixes and the cstb failed to disclose to the BBA the adverse test result 5B in late 2004 on cassette which yielded a Class E

01:41:12 when you come to consider iconic's role as it has presented it to you in its submissions you will I think struggle to find a single admission of fault on its own

01:41:23 single admission of fault on its own part

01:41:23 part uh alcoholic's case is that it was wholly blameless

01:41:32 next celotex it seeks to allocate blame like this on the night of the fire the ACM panels were to blame the external fast spread at grenfell was

01:41:44 the external fast spread at grenfell was caused by those panels the contribution of RS 5000 was it says minimal acmpe is incapable ever of complying with the functional requirement B4 on external fire spread celestex wasn't

01:41:57 external fire spread celestex wasn't involved in choosing it it was iconic who concealed the relevant fire safety tests relating to cassettes and continue to sell them long after they should have been withdrawn and specifically did so

01:42:08 been withdrawn and specifically did so for Grandville Tower through Deborah French its UK sales representative in April 2014 knowing that cassette was only ever Class E and rivet from 2013 a

01:42:20 only ever Class E and rivet from 2013 a Class C

01:42:21 Class C the same fire spread outcome it says would have obtained had mineral will been used see Bisbee on toxicity most of this toxic smoke says celatex came from the ACM

01:42:35 says celatex came from the ACM the building failed to resist internal fire and smoke spread because of the failures by rbkc and the TMO to comply with their obligations under the fire safety order 2004 not least in respect

01:42:48 safety order 2004 not least in respect of door closers the refurbished aov in turn implicating rbkc X over and PSB and the lifts not being upgraded to firefighting lifts

01:43:00 being upgraded to firefighting lifts in general explains blames the construction professionals each of them Studio e Ryden and Harley facades in failing to

01:43:11 Ryden and Harley facades in failing to perform their design and compliance obligations and not understanding the regulatory regime the routes to compliance or how the system at grenfell Tower could ever properly comply

01:43:23 Tower could ever properly comply none of them investigated the fire performance characteristics either of fr-5000 or rs-5000 which replaced it indeed Studio e through Mr Crawford simply took it on trust from Harley that

01:43:34 simply took it on trust from Harley that RS 5000 was compliant none of them investigated the fire performance characteristics of raynerbond acmpe none of them had requisite experience for their roles including a residential high-rise

01:43:46 including a residential high-rise Ryden itself together with its subcontractor sdpl made the decision to use

01:43:52 use tp-4000 combustible insulation around the inside of the windows contrary to approved document B contrary to the NBS specification and with no expertise at all that contributed to the spread of

01:44:04 all that contributed to the spread of the fire from the kitchen of flat 16 into the cladding system uh for its part it blames Max Fordham for

01:44:15 for uh for um failing to point out the fire characteristics and failing to investigating the fire characteristics of fr5000 when recommending it for use on grenfell Tower because of its thermal

01:44:27 on grenfell Tower because of its thermal values

01:44:29 values uh X over it says failed to carry out a comprehensive fire safety strategy and gave wrong advice that the proposed refurbishment Works would have no adverse effect on the building in relation to external fire spread and

01:44:41 relation to external fire spread and gave further wrong advice in both September 2014 and March 2015 rbkc's building control well they fail to carry out any proper investigation or inspection and should never have issued

01:44:52 inspection and should never have issued the completion certificate in particular Mr Hoban didn't investigate what route to compliance was being followed and if linear how the components met the guidance and dclg

01:45:03 guidance and dclg it failed to cure the problems inherent in the ambiguities in class naught and its unsuitability and what filler meant in 12.7

01:45:13 celatex does accept blame for misdescribing the RS 5000 test rig on the 2nd of May 2014 in its sales literature but it also says that it's marketing literature for RS 5000 was

01:45:25 marketing literature for RS 5000 was clear that any deviation from the system as tested had to be considered by the building designer and it wasn't and although it accepts that the description of the test was misleading nobody was

01:45:36 of the test was misleading nobody was misled because they didn't read it properly have they done so they would see that the build-up described was very different in many respects from the system proposed for grenfell Tower she such that the misdescription the

01:45:47 such that the misdescription the emission of the layer of magnesium oxide in the rig was not causative put another way the misleading emission of the magnesium oxide layer can't have made a difference because the rs-5000 test rig

01:45:58 difference because the rs-5000 test rig and the grenfell tower build up would say obviously different to anyone who cared to look cellotex doesn't I think appear to acknowledge at least in its overarching

01:46:09 acknowledge at least in its overarching closing any responsibility for rigging the May 2014 test as as it admits did happen and inserting a layer of magnesium oxide onto it in strategic places to get it to pass in the first

01:46:21 places to get it to pass in the first place as Mr Roper and Mr Hayes told you when they gave evidence before you you will have to consider the causative role if any if any that the pass in that way

01:46:34 if any if any that the pass in that way at the time played which enabled RS 5000 to come on to the above 18 meter Market in the first place while we're on insulation

01:46:46 kingspan now it admits and It quotes deeply regrets unquote what it calls quotes shortcomings quotes in its testing and its certification of k-15 for nine years

01:47:00 its certification of k-15 for nine years that I don't think it's unfair to say is where it's acceptance of responsibility ends it seeks to distribute culpability thus

01:47:09 thus the acmpe panels it wasn't safe to use them with any kind of insulation and those panels were solely responsible for the speed and spread of the fire so whether the

01:47:20 spread of the fire so whether the insulation was combustible or not would have made no difference to the fire spread and as Mr Webb KC for kingspan told you this week the presence of ACM effectively eclipses everything else

01:47:33 effectively eclipses everything else the government next gets the blame for allowing combustible insulation to be used in a system tested under 8414 a system which kingspan is Keen to use

01:47:45 system which kingspan is Keen to use even today it gets the blame for not Banning acmpe when it knew how it behaved from the CE 1924-2001 full system tests and forever seeing a LAX

01:47:57 system tests and forever seeing a LAX regulatory regime curiously kingspan also makes adverse comment about the inquiry team's approach to the evidence for thinking until the Bisbee experiments very late

01:48:08 until the Bisbee experiments very late on in phase two that the combustible insulation played some role in the fire spread on the night and the safety of systems incorporating k-15 in general there is a thinly veiled attack on our

01:48:21 there is a thinly veiled attack on our line of questioning of kingspan's witnesses kingspan can rest assured I hope that its submissions on these points will be considered with all seriousness all the evidence will be

01:48:32 seriousness all the evidence will be considered in the round and due to reflected in your report and any corrections will be made if and where they are Justified and necessary

01:48:43 they are Justified and necessary it is only fair to point out though to you and to the public lest you receive a one-sided picture that there is much that kingspan has chosen not to address or to explain in its closing it admits

01:48:56 or to explain in its closing it admits what in its written closing it politely calls shortcomings in its testing and sales strategy without going into or explaining how they came about or their effect on the insulation Market

01:49:07 insulation Market so you might ask well what do they say about the sale of a product that had not actually been tested the Reliance for on a decade for a decade on that test

01:49:19 decade on that test what do they say about the sales literature claiming safety generically of use over 18 meters I think what they say about that is that that had all been corrected by the time King span got onto the building

01:49:30 King span got onto the building what do they say about the failure to correct a BBA certificate which said that k-15 was compliant with paragraph 12.7 of ADB the use of an labc certificate which said that k-15 quotes can be considered

01:49:43 said that k-15 quotes can be considered a material of limited combustibility on quotes extracted from a hapless herefordshire building control officer quotes without getting even getting any real ale down him unquotes

01:49:56 real ale down him unquotes and the way it deflected the nhbc's questions and those of others such as wintech for a long time years in fact about how k-15 could be used over 18 meters if following the guidance in ADB

01:50:11 meters if following the guidance in ADB kingsman's case is that that is all irrelevant because in fact k-15 can be used above 18 meters safely or at least meet the criteria in br135 as later

01:50:23 meet the criteria in br135 as later tests appear to show and moreover only a small proportion of the insulation used on grenfold Tower was k-15 now those matters are doubtless important and you will have to examine

01:50:34 important and you will have to examine and weigh them carefully particularly in light of the submissions about the role of the k-15 which ended up on the tower as having any causative effect on the fire spread on the night

01:50:46 fire spread on the night but they're not the only points the importance of kingspan's evidence is what it revealed about its shortcomings about its attitude to the testing regime its use of the bre and its attitude to

01:50:59 its use of the bre and its attitude to certifiers and its customers and its effect and influence on The Wider Market from 2005 including on later arriving manufacturers like celetics trying to

01:51:10 manufacturers like celetics trying to access the over 18 meter Market which had been dominated for so long by kingspan and in turn on a large section of the building control profession via

01:51:21 of the building control profession via the nhbc

01:51:22 the nhbc on those matters kingspan in its in its overarching closing at least has chosen to stay silent despite what it knows that the bsrs and many other core participants say about those matters

01:51:37 Harley let's look next at the design team responsible for the grenfell tower refurbishment starting with Harley The Specialist cladding subcontractor Harley accepts what it calls

01:51:48 Harley accepts what it calls shortcomings failings and omissions and does not expect to be airbrushed out of the narrative as you were told but it does not appear to accept any particular blame

01:51:59 particular blame it seeks to allocate blame like this manufacturers there they are kingspan celotex iconic for deliberately pushing unsafe materials onto an unsuspecting Market by what it says was dishonest and

01:52:12 Market by what it says was dishonest and unethical methods including rigging tests and suppressing the dissemination of test results the bre comes in for its share of blame in failing to identify the manifold

01:52:23 in failing to identify the manifold errors in kingspan's 2008 BBA certificate for k-15 and the same in 2009 in relation to the labc certificate uh the BBA and the labc certificates

01:52:36 uh the BBA and the labc certificates were themselves misleading as was the nhbc's uh July 2016 guidance they must take some of the blame for promoting ACM so long as it could achieve Class B uh

01:52:48 so long as it could achieve Class B uh k-15 and rs 5000 above 18 meters in fact altogether so far as concerns the BBA certificate for the ACM Harley says that it's irrelevant even had Rainer Bond PE 55 in

01:53:01 irrelevant even had Rainer Bond PE 55 in truth had a class naught classification and even had Harley read it closely none of that would have ensured that Rhino Bond ACM PE 55 was safe

01:53:12 Bond ACM PE 55 was safe it is not clear how that is consistent with its case that iconic is to blame for peddling unsafe panels and there's no mention of the fact that the panels both in the rivet and the cassette fixes

01:53:23 both in the rivet and the cassette fixes appear to be covered by the certificate or at least not excluded the reason for that may be that nobody had hardly actually read the certificate sufficiently carefully to be induced to act on what it said about those fixes on

01:53:36 act on what it said about those fixes on one interpretation of the certificate central government gets its share of the blame for a number of things failing to or refusing to learn and publicize the

01:53:47 or refusing to learn and publicize the lessons from past fires failing to make public the results of the government's own to a 2001 1924 project tests on ACM PE which resulted in a very Fierce Fast Fire

01:53:59 in a very Fierce Fast Fire the view of the bre's own top fire scientist Dr Debbie Smith that ACM could not be an appropriate product for use in a high-rise application retaining class not despite itself

01:54:11 retaining class not despite itself evidently self-evident unsuitability because the ACM PE which so spectacularly failed in the 1924 tests in 2001 achieved class naught as a product and one might add despite the

01:54:24 product and one might add despite the night the 1999 parliamentary select committee recommended whether it be dropped

01:54:30 dropped uh failing to maintain a safe comprehensive and comprehensible system of fire safety regulation and confusion at the very highest levels of expertise Dr Smith and Brian Martin about the

01:54:43 Dr Smith and Brian Martin about the interchangeability of class naught with limited combustibility if they did not know that they were not interchangeable then how could Harley have been expected to know

01:54:55 to know it was all about the materials says Harley and not the designer installation witnessed the catastrophic failure of the post-grenfell fire test set up by the government using those materials and with cavity barriers in perfect

01:55:07 with cavity barriers in perfect Conformity with ADB and Harley also points out that it was not a specialist facade engineer or a cladding designer but a cladding subcontractor

01:55:18 subcontractor engaged to productionize someone else's design and specification and Reliant entirely on specialist architectural and other input from Studio e Ryden

01:55:31 other input from Studio e Ryden rbkc X over and the clerk of Works in other words everybody else now there's a conundrum on the BBA

01:55:43 now there's a conundrum on the BBA certificate for the brainer Bond PE 55 for you to resolve and I've already touched on it on the one hand it might be said that the document never caused any harm because nobody on the design team read it or read it properly and

01:55:56 team read it or read it properly and therefore the potentially arguably misleading nature of the document had no causative effect at all on the other hand it could be said and Harley seemed to say just this

01:56:07 to say just this that there was no point in them reading it as it would simply have confirmed what they already thought namely that ACM with a PE Pat core could be used above 18 meters and so nobody was harmed

01:56:18 above 18 meters and so nobody was harmed by their failure to read it the certificate certainly did not tell them that they could not use that product above 18 meters it could also be argued that by not reading it Harley saved itself from

01:56:29 reading it Harley saved itself from being misled by what it did say particularly in relation to the two fixing systems so even if the document was misleading it made no odds because no one on the design team or at building

01:56:40 no one on the design team or at building control read it properly now one way through that might be to say that ACM with a polyethylene core could on no view ever be used safely in accordance with the functional

01:56:52 accordance with the functional requirement B4 in the building regulations and that ought to have been obvious to everybody and that is a conclusion that you might if you look hard enough find supported by the factual and the expert evidence

01:57:03 factual and the expert evidence and one answer to the point about the color of the panel that smoke silver wasn't covered by the certificate is or might be that had hardly been told that neither rivet nor cassette fix was a Class B which was the position uh it

01:57:16 Class B which was the position uh it seems by early 2014 then it is unlikely that Harley would ever have needed to ask about the color since the BBA certificate would have been a dead letter

01:57:27 Ryden they're next up the design team chain their view is that they are wholly blameless and they seek to allocate blame like this government and the path

01:57:38 blame like this government and the path to grenfell this is as I think by now is becoming apparent low-hanging fruit and doubtlessing common with everybody else who bought and used acmpe incident and combustible insulation in the years

01:57:49 combustible insulation in the years before the grenfell Tower of fire but it is useful to delineate the targets here um we have the government and the path to grenfell First and Ryden blames the failure of

01:58:01 and Ryden blames the failure of government oversight of the operation of the post-1984 regulatory regime all to recognize signals from industry or fire experiences Paving the way for unscrupulous and dishonest manufacturers

01:58:14 unscrupulous and dishonest manufacturers to exploit customer confusion to suborn weakened plant certification bodies who had lost their objectivity and into publishing these leading certificates and to blame test houses for their

01:58:26 and to blame test houses for their possible connivance with clients to deceive the market and in any event the loss of their true Compass North when it came to conflicts of interest harmonization and the resultant shambles

01:58:39 harmonization and the resultant shambles is the word they use over diagram 40 equating class naught with class B or at least giving the appearance of doing so retaining class naught after the 1999

01:58:51 retaining class naught after the 1999 Select Committee reported to Garnet court or rather after Garnett Court again traceable to the harmonization exercise that took place in the summer of 2000 and 2001 after the May 2000

01:59:02 of 2000 and 2001 after the May 2000 radar report on reaction to fire spread covering up the 1924 tests from 2001. or at least inexplicably not disclosing

01:59:13 or at least inexplicably not disclosing them

01:59:15 them filler The Edge fire and the late coming amendment to 12.7 in the dying months or weeks of 2005 2006 and the introduction of filler without consultation even with BRAC and

01:59:27 without consultation even with BRAC and without taking steps to ensure that it was understood across industry blacknal and the unlearned lessons including the lesson of downward fire spread

01:59:39 spread post 13 inquest failures to act the inadequacy of class naught is a metric for assessing fire performance in external wall buildups br135 comes in for a particular blame as

01:59:51 br135 comes in for a particular blame as a failure Criterion only which cannot show that a particular buildup tested and which doesn't fail the criteria will meet regulation B4 Mass Market confusion witness again the

02:00:04 Mass Market confusion witness again the 2nd of July 2014 cwct meeting and the labc registered detail for RS 5000 of August 2014. and then you have an hpc's July 2016

02:00:16 and then you have an hpc's July 2016 guidance note promulgated at that conference on the 7th of July you'll remember that as telling readers building Control Officers that approved

02:00:27 building Control Officers that approved inspectors that class B ACM panels if you could find them and rs 5000 or k-15 were compliant not just in following the linear route but with the building regulation itself

02:00:41 and sell effects in kingspan Ryden says they exploited the broken nature of the regime for their own ends to create a false market for insulation above 18 meters and celex missiled rs

02:00:54 above 18 meters and celex missiled rs 5000 to Harley for use on grenfell Tower specifically and never disabused Harley of the notion that rs-5000 was suitable for use above 18 meters in any system the bre

02:01:05 the bre ath they failed in their obligations says Ryden of impartiality due to its privatization and it became a willing facilitator of cylotexes and kingspan's duplicity

02:01:16 duplicity there's a question about what Phil Clark knew about them the presence of the magnesium oxide boards on cele Texas 2nd of May 2014 RS 5000 test rig and you

02:01:28 of May 2014 RS 5000 test rig and you were going to have to resolve that question on the evidence

02:01:33 iconic they actually knew that their product whether in Rivet or cassette fix was dangerous and should never have been used of height says Ryden and says ride and iconic knew that it was being used

02:01:45 and iconic knew that it was being used at grenfell Tower because Deborah French had sold it to Harley using the BBA certificate for that very purpose despite being told on the 3rd of February 2014 that all brainerbond 55pe

02:01:59 February 2014 that all brainerbond 55pe was class E and the BBA who are up there now their certificates for both renewable and 55pe from January 2008 and k-15 from October

02:02:11 from January 2008 and k-15 from October 2008 were inaccurate and materially misleading and when it came to the Grenville Tower refurbishment project itself X overall so it comes in for some blame

02:02:22 X overall so it comes in for some blame uh paragraph 3.1.4 of the three issues of its outline fire safety strategy repeated three times given to tenderers

02:02:33 repeated three times given to tenderers in late

02:02:34 in late um 2013 which provisionally blessed the clouding system as safe it's advice it says it says Ryden was misleadingly and materially incomplete so far as concerned the cladding

02:02:46 so far as concerned the cladding Xavier continued to be retained by the TMO and to give ad hoc advice from time to time

02:02:51 to time it says that xaver should have completed its work as promised before Ryden was appointed and should have known that contractors and subcontractors would rely on its ofss the outline fire safety

02:03:03 rely on its ofss the outline fire safety strategy but even had X overdone its work properly and considered uh raynabon 55pe and rs 5000 there is doubt whether it would have considered their use of

02:03:14 it would have considered their use of grenfell tower to be inappropriate anyway

02:03:17 anyway Studio e that comes in for blame because Ryden it says fairly delegated design responsibility to it and it says it fairly had no doubts about its

02:03:28 it fairly had no doubts about its competence and had no reason to doubt it and Harley facades also gets blamed because Ryden they say it says expected it's clouding subcontractor to have technically competent people for

02:03:40 technically competent people for Technical and design matters Harley took full responsibility for ensuring compliance with the building regulations and the design work but what about Ryden itself

02:03:52 but what about Ryden itself it says it was a victim of government and other bodies a victim of Manufacturers it knew nothing of Studio ease or Harley's lack of knowledge or understanding it reasonably relied on

02:04:03 understanding it reasonably relied on them in a standard design and build setting and it had no alert from rbkc's building Control Department who who at times was

02:04:15 Control Department who who at times was described by Mr Lawrence as part of the design team now you have no expert of course to say that Ryden fell below the standard set in the contract with the TMO and that is

02:04:26 in the contract with the TMO and that is the point you will need to consider with some care when it comes to assessing what the objective standards are against which Ryden is to be judged other than its contractual obligations but you do have the expert evidence of Mr sacula

02:04:37 have the expert evidence of Mr sacula and you do have the evidence of Mr Hyatt which Bears on that as well as the opinions of Dr Lane but

02:04:46 but looking at the map here Ryden isn't to blame for anything by its own lights

02:04:53 Studio e is next now Studio e has not provided any overarching observations and has not appeared this week to address you about these bigger themes we have to work therefore with the

02:05:05 we have to work therefore with the position uh expressed already in its submissions but as you heard at the end of module one its position is basically defensive there is an open question to what extent

02:05:16 there is an open question to what extent it has reflected on the quality of the services it rendered and asked itself whether the level of quality of its service contributed in any material way to the deaths at grenfell

02:05:27 to the deaths at grenfell you will carefully consider those submissions long ago though they were and weigh them against all the evidence and those of the expert opinions of Mr Hyatt should you choose to accept and

02:05:38 Hyatt should you choose to accept and rely on those opinions and to that extent

02:05:43 X over X over on its case was blameless you heard that this morning any emissions were not causative it seeks to lay the flame as follows

02:05:55 flame as follows government and the regulatory regime class naught ADB Etc that did a regulatory agenda it seeks to blame the manufacturers who

02:06:06 it seeks to blame the manufacturers who says exover were engaged in deliberate malpractice to exploit weaknesses in the regime

02:06:11 regime and specifically to control the dissemination of test data in respect of actively marketed products building control bodies developers and Lead contractors the certification

02:06:22 Lead contractors the certification bodies BBA and the labc or and the whole structure of design and build where participants can oversee projects without real expertise of their

02:06:33 projects without real expertise of their own and without identifying necessary specialist expertise to be contracted in and without identifying who needs to be managed and what needs to be coordinated and you might add who had what

02:06:46 and you might add who had what responsibility

02:06:49 and in that light the way in which the grenfell Tower refurbishment project was set up

02:06:54 set up with numerous disconnections both before and after the award of the main contractor rolled to Ryden and particularly the absence thereafter of a design responsibility Matrix and who was

02:07:05 design responsibility Matrix and who was responsible for what such that everyone thought that the compliance of the of the facade with with the functional requirements so far as regards fire was someone else's

02:07:16 far as regards fire was someone else's responsibility rather mirroring the submissions ex-saver blames two key decisions you heard this this morning first to use the

02:07:27 heard this this morning first to use the aluminum composite material with a polyethylene core as cladding and secondly to use it to form the crown but it doesn't appear to draw any link between the presence of that material on

02:07:38 between the presence of that material on the tower and anything done or not done by X over

02:07:44 by X over it it essentially says those decisions had nothing to do with it that may be right it may not be right you will have to examine the evidence with some care next the TMO

02:07:56 next the TMO now the TMO it is fair to point out as it does exists for the purpose only of responding to any civil or criminal proceedings and for assisting this inquiry and it is inappropriate for

02:08:08 inquiry and it is inappropriate for those appointed post-fire it says to express any judgments critical of its conduct in respect of the refurbishment it makes a number of defensive points

02:08:19 it makes a number of defensive points that of course again you are going to have to consider carefully for example the fact that the grenfell tower fire could have happened to anybody in the sector and the fire itself revealed hundreds of high-rise

02:08:31 itself revealed hundreds of high-rise buildings across 25 local authorities with cladding which failed the post-fire tests done by the government it says that the TMO was no better and

02:08:42 it says that the TMO was no better and no worse than other social housing bodies or private bodies acting as a client for a refurbishment involving cladding that hindsight expressions of things that could have been done differently are not to be equated with culpability

02:08:54 culpability and that the multifaceted causality of disasters such as Grenville Tower where many errors accrete and intersect and align in particular circumstances

02:09:05 and align in particular circumstances the TMO has focused tightly on the scale of the ACM problem across the UK housing estate

02:09:12 estate from that it reasons that in installing a cladding system with combustible materials it didn't act out of the norm even without a benchmarking survey it then goes on from that beginning to

02:09:25 it then goes on from that beginning to blame first the acmp panels for the fire the concealment of the true results of the testing of raynerbond PE 55 and the bees and the BBA certificate

02:09:36 bees and the BBA certificate it blames iconic's deliberate targeting of countries which continue to operate with both a national and a European Standard it blames the BBA it blames class not basic unsuitability as a

02:09:49 class not basic unsuitability as a standard for external surfaces the misunderstanding by the industry of what class naught actually meant and its retention for political purposes by the government it blames the non-disclosure by the

02:10:01 it blames the non-disclosure by the government of the disastrous c-1924 tests in 2001 on ACM with a PE Corps notwithstanding the government well understood the implications and it blames the government for failing

02:10:13 and it blames the government for failing properly to respond to the local Coroner's rule 43 recommendations he blames the government's knowledge not limited to Brian Martin that there were serious problems with approved document

02:10:25 serious problems with approved document b and a prime case existed for Urgent review it blames the rigging of RS 5000 texts by sellotex and its misleading marketing and similarly misleading

02:10:36 marketing and similarly misleading marketing of k-15 by kingspan and it relied on the design team it had quite reasonably it says appointed as client to run the grenfield Tower refurbishment project artelia

02:10:48 refurbishment project artelia Studio e as architect and Lead consultant and lead designer Ryden as contractor a rational appointment it is said given its track record and the terms on which it was appointed to ensure that

02:11:00 it was appointed to ensure that materials and construction were compliant with regulation value engineering the price of cladding down it says wasn't only normal but not causative because the ACM with

02:11:13 but not causative because the ACM with the PE Court had already been pushed by Harley pre-contract and included in the NBS specification anyway as an alternative to zinc and even suggested by leadbitter at a much earlier stage

02:11:25 by leadbitter at a much earlier stage before Ledbetter decided not to participate in the re-procurement exercise in 2013. it blames problems with the self-closing

02:11:36 it blames problems with the self-closing doors and far doors as widespread across the whole social Housing Industry there was an endemic problem cured I think only this year by new regulations which showed that the TMO clearly wasn't out

02:11:47 showed that the TMO clearly wasn't out of the norm the point being made is that um if there was a problem that has been cured by legislation and the need to cure it by legislation shows that the TMA wasn't acting unreasonably that I

02:11:58 TMA wasn't acting unreasonably that I think is how the point runs so far as um the aov and the lifts are concerned the TMO expected that they were properly maintained and that the aov system was never

02:12:10 and that the aov system was never designed to handle that much smoke in one go

02:12:13 one go Carl Stokes he gets some um blame well he gets praise actually for being up to the job according to the standards of the day and the TMO had no reason to think otherwise

02:12:24 think otherwise and the RO for its part was unclear as to whether it extended to the external wall a controversy now cleared up again in the recent new legislation

02:12:35 in the recent new legislation and finally peeps the TMO was not acting out of the norm in not having them now that is the the very basic message that the TMA would want you to take away

02:12:46 that the TMA would want you to take away from the evidence if the TMO has asked itself the question did anything we did or did not do have any causative role in the fire or the deaths or any material bearing on what

02:12:58 deaths or any material bearing on what happened in that building on that night it is not Apparent from the position that they have taken in their overarching submissions now that may be of course because it had no causative

02:13:09 of course because it had no causative role directly or indirectly it may be that it simply isn't to blame at all

02:13:14 at all or it may be that on a closer analysis of the way that the refurbishment project was set up and staffed or the way that it sought to discharge its responsibilities for the building under the FSA

02:13:26 building under the FSA of the way that it handled its residence in respect of the refurbishment shortcomings are revealed that did bear on the fire or on the deaths

02:13:37 on the fire or on the deaths I'm afraid you will have to work that out yourselves from the evidence but unaided by admission or self-examination by the TMO or the husk of it that remains

02:13:50 let's look at rbkc now rbkc has unqualifiedly admitted important failures in its building control service it did that at a reasonably early stage

02:14:03 it did that at a reasonably early stage it says and it repeated the point this week through Mr Maxwell Scott Casey that it should never have been the case that all that stood between the installation of Rayne Bond PE 55 and rs-5000 on

02:14:14 of Rayne Bond PE 55 and rs-5000 on grenfell Tower was the building control service of a local Authority

02:14:20 rbkc also said yesterday um by way of a list that it had failed without qualification the list was both welcome and pithy and

02:14:31 the list was both welcome and pithy and you will take note of that Mr Maxwell Scott made it plain that rbkc's submissions about how blame might lie elsewhere do not detract from its acceptance of its failings

02:14:42 acceptance of its failings rbkc has presented a helpful roadmap of key events which each act as a prism to see its case about who was really responsible filtered through that prism we see that

02:14:53 filtered through that prism we see that rbkc allocates fault in very general terms 2. iconic celotex the long history of the evolution of the regulatory environment from nosley in 1991 to grenfell in June

02:15:06 from nosley in 1991 to grenfell in June 2017 and among other things class naught's unsuitability the lack of focus and funding for research on fire safety of materials designed to increase Energy Efficiency in line with government

02:15:18 Efficiency in line with government policy Connolly 1994 radar 2000 and the so-called equivalents with euroclass B enshrined in the 2002 amendments to Aid to ADB

02:15:29 to ADB and they see 1924 tests in 2001 and the government's failure to disseminate the results until after the grenfell tower fire when it was the BBC who broke the story

02:15:40 story weaknesses in the testing and certification regime particularly the LA BC and the BBA exovers response to Studio E's request on the 17th of September 2014 about RS

02:15:53 on the 17th of September 2014 about RS 5000 and its failure to advise that that material was not Material of limited combustibility and therefore could not be used under 12.7 of ADB and its failure thereafter particularly after

02:16:06 failure thereafter particularly after that exchange to update the outline fire safety strategy and provide the promised future issue dealing with external fast spread and to confirm the provisional positive view finally

02:16:18 positive view finally it blames writing for failure to appoint a fire consultant despite a number of indications that it would do so from first of April 2014 and despite not having an in-house resource explained in

02:16:30 having an in-house resource explained in part by treating the building controlled body at rbkc as that resource and the design team Studio e and Harley facades

02:16:40 facades rbkc has also repeated its admissions in respect of its oversight of the TMO in respect of the safety measures in place at grenfell Tower and elsewhere in the borough in that respect it blames the

02:16:51 borough in that respect it blames the government

02:16:55 uh for failure to regulate the competent standards of fras after lachenal despite siren calls for it to do so it blames the TMO for the way in which Carl stokes's role expanded without a proper

02:17:07 stokes's role expanded without a proper procurement process having no concerns about his work despite the lfb expressing their own concerns at a level of volume and not being cited on his

02:17:18 of volume and not being cited on his work

02:17:18 work it blames the flat front doors which were not properly fire resistant fd-30s doors compliant with the building regulations uh and that was a generic problem on a

02:17:29 uh and that was a generic problem on a national scale it accepts qualified blames in respect of the scds the self-closing devices on doors but seeks to pass that on to the TMO for giving it incomplete information

02:17:40 TMO for giving it incomplete information and as a result elected for a five-year installation and not a three-year program and no inspection program and the scale of the defects

02:17:51 and the scale of the defects not known to rbkc

02:17:55 and it blames Mr Stokes for failing to advise that there should be a planned maintenance program and six monthly inspections as per the LGA guide and the fact that he himself only

02:18:06 and the fact that he himself only inspected a small sample as you can see we now come to central government the dclg or the mhclg as it had become

02:18:17 the dclg or the mhclg as it had become when the inquiry started and now the dluhc

02:18:20 dluhc it has made broad admissions of fault in respect of the regulatory regime for the most part although less so in respect of the fire safety order and the related

02:18:32 the fire safety order and the related guidance there however in respect of how the building came to be as it was on the night of the 14th of June 2017. it has made pithy but pointed criticism of each member of the

02:18:44 pointed criticism of each member of the design team so the TMO artelia Studio e Ryden Harley facades X over John Rowan

02:18:56 Harley facades X over John Rowan and RB Casey's building control the department says that they all displayed in different ways a fundamental failure to give any real thought to the most basic aim of the

02:19:08 thought to the most basic aim of the building regulations namely the protection of people's safety Health and Welfare in and around buildings when it should have been front and center of everything they were doing this failure LED them to minimize the

02:19:19 this failure LED them to minimize the importance of compliance with the building regulations and this led in turn to the tragic events of 14th of June 2017. but

02:19:28 but the department does not appear to have reflected on is how those failings apparently so commonly shared are linked in blameworthiness terms or causatively

02:19:40 in blameworthiness terms or causatively to the failings that it has identified in its own development and oversight of the regulatory regime which it accepts were broken why were all these individuals and

02:19:52 why were all these individuals and organizations so lacking incompetence in that single Arena fire safety under the building regulations why this Ship of Fools it was clearly not a coincidence

02:20:03 it was clearly not a coincidence the department says that no competent design or construction professional would knowingly have utilized combustible cladding and insulation with the properties of those used at grenfell in the refurbishment of that building

02:20:14 in the refurbishment of that building and it relies in turn on the expert evidence given by Professor Bisby but beware any shortcut to causation here you will need to weigh that approach to causation with the role that ADB and

02:20:26 causation with the role that ADB and particularly class naught actively did play in the minds of those involved

02:20:32 involved and the uses and abuses of bs-8414 and br135 developed out of fire note 9 in the late 1990s as an alternative way of meeting compliance

02:20:44 meeting compliance the department also blames the trio iconic celatex and kingspan for what it calls cynical and dishonest practices in the testing and marketing of their products it blames the bre

02:20:57 products it blames the bre four its finality my word presiding over weak practices and the BBA and labc for incompetent and misleading certification but again what are you to make of the

02:21:10 but again what are you to make of the Department's role in facilitating or creating the environment for the kinds of practices and attitudes that you might conclude that the evidence reveals if a manufacturer can think

02:21:21 if a manufacturer can think and here you may recall kingspan's Aaron chalmers's colorful internal texts that it is within the testing regime to test only the foil facer of an insulation panel for class naught and

02:21:34 insulation panel for class naught and then have X over through Mr Fran's Pap bless that approach albeit with caveats it is fair to point out as arguably within the letter of the regime you might look again at the

02:21:46 regime you might look again at the testing and classification regime and ask yourself to what extent it facilitated that conduct now it's for you to assess whether the several and separate instances of manufacturer behavior in testing and

02:21:57 manufacturer behavior in testing and selling their products was again just a coincidence or whether it had a common route in the UK's regime as a seed bed for practices such as kingspan now

02:22:08 for practices such as kingspan now regrets as what it prefers to call shortcomings

02:22:14 the BBA in paragraph three of its written closing submissions the BBA says it says this to the extent that the BBA made

02:22:25 this to the extent that the BBA made errors and mistakes it offers an unreserved apology is that an admission of errors and mistakes or is that an offer of an apology for any error that you might

02:22:36 apology for any error that you might decide that it made without actually admitting any it's an I'm sorry if not I'm sorry for now the BBA fairly points out that it is

02:22:48 now the BBA fairly points out that it is a small private has no role in standard setting and its role is entirely contractual it has no Paths of compulsion beyond the contract no means of stopping unscrupulous clients misleading them it isn't a testing house

02:22:59 misleading them it isn't a testing house it was certified by ucas against ISO standard 17056 and 2012. certification isn't mandatory the process isn't regulated by the building

02:23:10 process isn't regulated by the building act or the regulations or the approved documents certificates are designed to be read by train Specialists and qualified designers whoever they may be and it doesn't tell you about the safety

02:23:21 and it doesn't tell you about the safety of a building or design only a product but

02:23:26 but the BBA was also a vital Gateway to the public market and its certificates were a valuable kind of currency in the hands of manufacturers BBA admits

02:23:38 BBA admits that reissues were not always followed up a weakness revealed by the evidence here

02:23:44 here it admits that the statement on the front page of the 2008 BBA certificate for Rayne Bond PE 55 was allegedly capable of misinterpretation because it wasn't limited to the FR

02:23:56 because it wasn't limited to the FR version the fire resistant version which had achieved an actual class naught it argues about the words may be regarded as opposed to can or does leaving it up to the reader to decide whether it can

02:24:08 to the reader to decide whether it can or can't or does or doesn't it accepts that the wording could have been tighter in that only some scenarios were covered not sure which but some it admits that its statement in the April

02:24:20 admits that its statement in the April 2010 certificate for kingspan k-15 which said that it may be used in accordance with among other Provisions approved document B 12.7 was correct

02:24:31 was correct correct because it could be used above 18 meters in a cavity created by two skins of masonry and any suitably competent reader would have understood that

02:24:41 that now you're you are going to have to decide whether that argument and it is an argument even though it was Advanced by Mr albon and again yesterday by Mr Sawtell for the BBA is any good I I

02:24:54 Sawtell for the BBA is any good I I would just point out one thing which is obvious I would say that the reference to masonry wall in section 12.7 is by way of an exclusion from the requirements of limit material of

02:25:06 requirements of limit material of limited adaptability in 12.7 it's a carve out

02:25:09 carve out so how the reasonable reader of the words in the certificate can be used in accordance with 12.7 would think that that referred only to the part of 12.7 which didn't apply uh is a question you

02:25:21 which didn't apply uh is a question you will no doubt Ponder although it is true that the BBA certificate did not say in terms that k-15 was material limited combustibility you will have to ask yourself how the

02:25:32 you will have to ask yourself how the reasonable reader might otherwise read the reference to 12.7 unless they already knew that phenolic insulation was not Material of limited combustibility and not within the requirement in which case the statement

02:25:43 requirement in which case the statement in the certificate was useless and pointless

02:25:46 pointless you might also consider whether the masonry wall argument sits at all with the contemporaries contemporaneous evidence in the discussions about it between Brian Martin and John Alban in the July of 19 of 2014 where the latter

02:25:59 the July of 19 of 2014 where the latter described the reference to 12.7 as a human error a rare and unfortunate oversight and not a deliberate but rather ham-fisted attempt to refer to the Mason reward exclusion

02:26:10 the Mason reward exclusion the point remains that as the BBA also said nobody should have been misled into thinking that a phenolic foam board could be material of limited combustibility but you might also think

02:26:21 combustibility but you might also think that that was at least on the evidence you've heard optimistic given the levels of expertise and competence among some designers and it appears certifying bodies themselves

02:26:32 bodies themselves the BBA also accepts in the BBA certificate for k-15 of the 27th of October 2008 that the statements the board

02:26:42 the board will not contribute to the development stage of a fire was it says capable of potential misinterpretation and was removed in 2015 and the statement that

02:26:53 removed in 2015 and the statement that the product met the br135 criteria was also quotes potentially misleading close quotes in that br135 was a set of system criteria not a product test

02:27:06 the BBA blames Studio e

02:27:11 Studio e the blame Studio e for doing a number of things first not inquiring about the color difference between the panel tested gray green and the panel proposed for grenfell smoke silver and in not

02:27:22 for grenfell smoke silver and in not insisting on a fire test first it's citing Hyatt and therefore using a panel not covered by the certificate but again as I say since no panel of any color at least in cassette form was ever actually Class B and thus equivalent to

02:27:34 actually Class B and thus equivalent to class naught you will have to work out how that helps all it means is that there was no classified panel for the BBA certificate to cover and that had a studio he opted for gray green there's

02:27:45 studio he opted for gray green there's no evidence that the outcome would would not have been exactly the same uh not being alert to the need for cavity barriers not noting section 6.5 in the certificate about reaction to fire for the performance of the wall as

02:27:57 fire for the performance of the wall as a whole but note the word reaction in that paragraph As opposed to resistance um two words which are terms of art under the under the regulatory regime and for falling for the reference in

02:28:10 and for falling for the reference in 12.7 to in the k-15 ref certificate and not knowing what the whole world knows that the certificate foam ball that a phenolic foam board is not Material of limited combustibility

02:28:21 limited combustibility but you do also need to exercise a little bit of care because and precisely the extent to which and when Studio e became aware of the use of k-15 on the tower at all is a matter of

02:28:34 k-15 on the tower at all is a matter of careful investigation it blames Harley for not paying attention to Clause 6.5 of the BBA certificate about reaction to fire of the whole wall and also for

02:28:46 fire of the whole wall and also for thinking that the reference in the BBA k-15 certificate to class naught was a gateway to above 18 meters for insulation thus muddling class naught and material of limited combustibility

02:28:58 and material of limited combustibility to different concepts it blames iconic for not disclosing the test results for certificate for cassette test 5B and for breaching its contract with the BBA in

02:29:09 breaching its contract with the BBA in not notifying it of changes in performance particularly at review in 2015 and renewal in 2016 when iconic knew that neither rivet nor cassettes were Class B and for representing to

02:29:21 were Class B and for representing to Harley

02:29:22 Harley and cep that Rainer bond 55pe in cassette form was covered by the certificate for use on grenfell Tower at a time when it knew that it any had achieved a Class E

02:29:35 that it any had achieved a Class E and it blames diagram 40 which singles out for special treatment within the regime for the equivalency inherent in the may be regarded

02:29:47 the bre ath now so far as the bre is concerned its basic position is twofold it says first that the cladding system installed on grenfell Tower was not tested under

02:29:58 on grenfell Tower was not tested under bs8414 to br135 had it been so tested it would not have met those performance criteria

02:30:05 criteria It also says second that the regulatory regime applicable to external walls above 18 meters including cladding systems on high-rise buildings was developed by an iterative

02:30:17 buildings was developed by an iterative and consensus-based process with the Department having ultimate responsibility for it now those are observations which are wholly uncontentious and could have been made on day one of this inquiry but with

02:30:29 made on day one of this inquiry but with great respect to the bre They Don't Really Advance matters the essence of the bre's position is contained in its module 6 written on oral submissions which you will need to digest and of

02:30:41 which you will need to digest and of which you must and I'm sure will take careful account are they propose to say anything more about that today just as I did not at the end of module 6.

02:30:52 now at this point it might be useful to show you what all of these different little maps of blame look like when merged

02:31:04 it looks like that

02:31:08 that is the web of counter of pointer and counter pointer who blames whom and I've explained for what

02:31:20 and I've explained for what now you will note that on that map there are a number of Corp participants not covered

02:31:25 covered and that is because I'm not going to cover nhbc ciderize PSB Max Fordham JS Wright all the other core participants who've made closing submissions that

02:31:36 who've made closing submissions that does not diminish the importance of their roles but I'm not sure that public understanding of causation and culpability will be improved by close analysis of their positions about

02:31:47 analysis of their positions about culpability by me here and a further obscuration of what is already a complex picture

02:31:54 picture nor am I proposing to cover the lfb the nfb have not generally sought to shuffle off responsibility onto others other than perhaps central government

02:32:05 other than perhaps central government and particularly in respect of the Commissioners and Senior fire safety officers warnings to central government even before lacknell and certainly afterwards about the dangers of tall

02:32:16 afterwards about the dangers of tall building fire and smoke spread its influence on evacuation and stay put and on the Ambit of the fire safety order all of that is the subject of detailed evidence from modules 5 and part 6 and

02:32:29 evidence from modules 5 and part 6 and module 6 part 1 which defies simple and neutral presentation

02:32:37 before I close as I am about to I would like to register publicly my thanks to the inquiry team as we have progressed through the modules

02:32:47 modules our team has decreased in size and to name everybody now would take some considerable time however I would like to thank Caroline featherston the solicitor to the inquiry and her current team of Kathy Kennedy

02:33:01 and her current team of Kathy Kennedy Shafi NASA Ross Howarth Julia Dickens Holly Waldron Roz tryhane holy war and Thomas wood for all their Good Humor

02:33:13 Thomas wood for all their Good Humor support and Clarity of purpose we have all had superb assistance from excellent paralegals whose work in many cases far exceeded the norm in expert

02:33:24 cases far exceeded the norm in expert judgment and knowledge of the documents I personally owe a particular debt of gratitude to Kate Grange King's Council and to Andrew Kinney at King's Council

02:33:35 and to Andrew Kinney at King's Council who have led so much of the work in both phases and have lightened so much my burden

02:33:41 burden I thank two the teams of our remarkable Junior Council involved in the preparation of each of the modules for this phase two I think particularly Rose Grogan Helena drage

02:33:51 drage Emma Hines Rachel Sullivan Rachel Troop George air Dan leaking Camilla Taha Shanti sivakumarun Bilal rawat Kate Fortescue

02:34:05 sivakumarun Bilal rawat Kate Fortescue Sam Bonner Samantha Jones Alice Alex Ustick David messling Tom cockcroft Hannah Curtin Scarlett Milligan Tim Salisbury Adam Gad Sam burritt Daniel

02:34:19 Salisbury Adam Gad Sam burritt Daniel O'Donoghue Sarah Reed Dermot Keating Priya Malhotra Xena Islam Vida semper nyam Asif

02:34:28 nyam Asif Lucy Plumpton and many I have not named here

02:34:31 here without there on stinting commitment to the work of this inquiry and to each other as a team and without their meticulous preparation their discipline their enthusiasm and

02:34:42 their discipline their enthusiasm and their persistence our task would have been impossible and your investigation far less effective I must also thank all the members of our excellent Secretariat headed for so long by Mark Fisher for their work behind the

02:34:55 by Mark Fisher for their work behind the scenes in allowing us to get on with our work without distraction or Interruption particularly through the turbulence of kovid

02:35:02 kovid I thank the witness care team Laura Brooks and Mel pfeffer our team of cheerful ushers and our security team who have had daily contact for so many months with the bereaved and the survivors and the families and the witnesses alike and who treated all

02:35:14 witnesses alike and who treated all those individuals with compassion and respect they are as much a part of our work as the evidence Gathering and assimilation and no thanks will be complete without a

02:35:25 and no thanks will be complete without a special tribute to our transcribers particularly Kayla and the indefatigable Joe whose patient accuracy and Keen ear to hundreds of days of evidence have been vital assets and to the Opus team

02:35:38 been vital assets and to the Opus team for their continual assistance and support

02:35:42 support and finally I should also recall publicly the inquiry is sadness at the sudden loss in August this year of our only recently installed new secretary to the inquiry Nicole Kett who in her short

02:35:54 the inquiry Nicole Kett who in her short time with us gave us so much wisdom insight and support it is now Matthew Matthew Lucy who takes up the Reigns as secretary and will carry the inquiry from here to its

02:36:06 carry the inquiry from here to its conclusion

02:36:09 members of the panel Mr chairman I first stood as inquiry Council and addressed you Mr chairman more than four years ago in May 2018 today exactly 400 inquiry days on by my

02:36:23 today exactly 400 inquiry days on by my calculation certainly 312 days on in this phase is likely to be the last time I do so as a final personal reflection I thank

02:36:35 as a final personal reflection I thank you the panel for your patience your attention and your constancy in listening and understanding it is now for you to report the task before you is immense but to

02:36:47 the task before you is immense but to the bereaved and the families and the survivors it should bring relief to the public the clarity of narrative and to policy makers a clear

02:36:58 and to policy makers a clear unavoidable and incontestable direction thank you very much thank you very much Mr millet well now having heard from all those

02:37:10 well now having heard from all those core participants who wish to make oral overarching closing statements and of course having heard from councils the inquiry we have completed the inquiries

02:37:21 inquiry we have completed the inquiries hearings

02:37:23 hearings when we reached the end of the modulate hearings in July I attempted to give a brief description of the next stage of the inquiries work

02:37:34 of the next stage of the inquiries work I also expressed then the panels thanks to all those who've done so much to enable our work and our hearings to be conducted in a dignified and effective

02:37:45 conducted in a dignified and effective way and I would on this occasion wish to associate all the members of the panel with the thanks expressed today by Mr Millet but also to thank him personally

02:37:57 Millet but also to thank him personally as leader of a large team of councils whose names you've heard read out without whom we simply could not have begun to embark on this enormous task

02:38:09 begun to embark on this enormous task I don't intend to repeat what I said on the previous occasion but I am pleased to confirm that work on our final report has already begun inevitably there is still a long way to

02:38:21 inevitably there is still a long way to go

02:38:22 go but as I said in July we are very well aware that we need to produce our report as soon as we can we are all therefore fully committed to

02:38:35 we are all therefore fully committed to pressing ahead as quickly as possible and we should ensure that we don't keep you waiting any longer than is absolutely necessary for now that closes our proceedings

02:38:47 for now that closes our proceedings and we shall be in contact again in due course thank you all very much and thank you particularly those of you those of you who have been here to

02:39:00 you who have been here to take part in I would say our proceedings there are many familiar faces sitting in the seats in front of me it's been a great pleasure to see so many of you on

02:39:11 great pleasure to see so many of you on many many occasions some on almost every occasion on which we've said and we very much welcome the fact that you've taken such a close interest in our work as I say Taken part in it by your very

02:39:22 say Taken part in it by your very presence thank you all very much

02:39:27 foreign