Phase 2 Overarching and Module 7 Closing Statements - Wednesday 9th November 2022 (2/2)

Full transcript

00:21:36 foreign

00:21:42 yeah now the next closing statement is going to be made by Mr agaros on behalf of the tenant management organization and I understand that he wishes to make his

00:21:53 understand that he wishes to make his statement remotely so

00:21:57 so I think we wait for a moment to see whether he's going to come up on the screen

00:22:17 um a very short moment ago and it's not how stuff can I ask whether you can hear me

00:22:24 me um if that's Mr agaros speaking in the background the answer is no uh only some disembodied voice and we can't see you either so I think the better course

00:22:37 either so I think the better course would be for us to rise for a moment we can now hear you but we can't see you and I'm sure everyone would like to see you as well as hear you yes we'll rise we just give me five minutes I'm really

00:22:49 we just give me five minutes I'm really sorry about this don't worry we'll rise for a couple of minutes and uh we'll ask the Usher to come and get us when you are the

00:22:57 are the um visible as well as audible all right thank you very much good thank you very much

00:23:02 much okay

00:27:58 well uh the panel is back again Mr agaros we we can now see you I'm very glad to say and can you hear me I can thank you very much sir and we can

00:28:09 I can thank you very much sir and we can hear you so great I do apologize for that um I'm afraid to say it happened literally just as we're about to start don't worry these things are easily done and um it's

00:28:21 these things are easily done and um it's all been rectified now yeah so can I say thank you first for allowing me to attend remotely from Birmingham where I'm conducting a case unfortunately I was in court this

00:28:32 unfortunately I was in court this morning otherwise I would have been there in person to deliver these submissions to you in person I'm sorry for not being here being there in person

00:28:43 official could you just pause a minute Mr agaros I'm sorry you've got you've got no

00:28:51 oh well not Mr angle I don't know whether you heard that um Miss stud has just risen to tell me that you're not appearing on the screens that the public can see

00:29:00 can see and I think the public should be able to see you

00:29:04 see you um

00:29:05 um so I'm going to ask the the Usher's just gone to speak to the technical people

00:29:14 so can I I ask can you can you see me I'm just checking whether it's my end or not no it's not your end as far as I can tell because we can see you and we can hear you

00:29:25 hear you um

00:29:26 um and apparently you appear on some of the screens in the room Mr study if you're very keen to see Mr eggaros

00:29:41 yes right I I think we've solved that problem as well well I haven't but somebody has that's the point so um

00:29:51 um we can ask you to carry on and let's assume everything's all right thank you very much well Sarah making these final overarching submissions the TMO appreciates that will not be helpful

00:30:03 TMO appreciates that will not be helpful to repeat submissions made previously or rehearse evidence heard before the inquiry in detail and so therefore I will avoid doing this as far as possible here however in identifying some of the

00:30:16 here however in identifying some of the themes the TMO considers to be key it will be necessary to go back over some of the ground previously covered as it has throughout the TMO expresses

00:30:27 as it has throughout the TMO expresses its sincere sympathy and condolences to those who lost loved ones during the terrible fire which occurred on 14th of June 2017 and it hopes that those who

00:30:38 June 2017 and it hopes that those who grieve may find some comfort in the years to come including through the findings of this public inquiry so as to the tmo's interaction with the inquiry generally although by March 2018

00:30:52 inquiry generally although by March 2018 the TMO ceased to exist as a body with day-to-day responsibility for the management of grenfell tower it has through its lawyers and remaining staff none of whom none of whom were imposed

00:31:05 none of whom none of whom were imposed before and at the time of the fire sought to assist the inquiry in achieving its aims including through the disclosure of thousands of documents and the provision of hundreds of witness

00:31:16 the provision of hundreds of witness statements including ones from Witnesses who gave evidence before the inquiry so TMA Witnesses gave evidence in modules one three and four

00:31:27 modules one three and four Some Gave evidence on multiple occasions and across a number of days and where the subject of detailed questioning many others gave statements but were not called to give evidence in person so the

00:31:39 called to give evidence in person so the inquiry will form his own view about each of the TMA Witnesses but it is submitted that all Witnesses who gave or 11 certainly did their best to engage and support the inquiries process

00:31:52 and support the inquiries process Council for the inquiry urge core participants not to engage in a merry-go-round a buck passing and it was remarked on that none of the core participants say for rbkc and now

00:32:04 participants say for rbkc and now possibly dlhc and the BBA has made any admissions before the inquiry this is not lost on the TMO however as the inquiry knows the TMO

00:32:17 however as the inquiry knows the TMO exists now only as an organization whose function is to respond to any civil or criminal proceedings brought against it the handful of Staff presently imposed were not imposed before the fire and had

00:32:30 were not imposed before the fire and had no dealings with the refurbishment so for these reasons it is not appropriate for those now employed to express critical judgments about the organization as it previously was or its

00:32:42 organization as it previously was or its employees this is especially so in a number of the individuals in question continues to be investigated by the police for serious criminal offenses so however the TMO understands that

00:32:55 so however the TMO understands that being the client for the project and the resident facing body for the refurbishment the inquiry will look carefully at the tiernos role this is only right and to be expected

00:33:07 only right and to be expected so at the end of all the evidence it's worth reflecting again on why the groundpool tower refersment occurred in the first place the intentions behind the refurbishment project were good ones

00:33:18 the refurbishment project were good ones the overriding intention was to improve the quality of residents lives by investing heavily in the building including in its energy efficiency so we say that it's important to keep

00:33:31 so we say that it's important to keep this in mind when assessing the actions and motivation of TMO staff as all their efforts were geared towards the Improvement of residents living conditions how the inquiry views the TMO Witnesses

00:33:44 how the inquiry views the TMO Witnesses is ultimately a matter for the inquiry but it is submitted that it would be entitled to conclude that all were well-intentioned social housing professionals and unactive with ill will or a reckless

00:33:56 and unactive with ill will or a reckless attitude towards residents health and safety

00:34:00 safety so it's been suggested that the TMO among other core participants may have been an institutionally racist organization certainly according to the first and definition

00:34:12 first and definition this is emphatically not accepted by the TMO nor indeed was accepted by any of the witnesses that gave evidence of the inquiry in fact sir no witness was questioned on the topic and the tiermost

00:34:24 questioned on the topic and the tiermost admits that it would be unfair in those circumstances to make such a finding without an evidential basis the inquiry will also determine whether the TMO and rbkc were as it has been put

00:34:37 the TMO and rbkc were as it has been put only interested in proving the look of the ground floor Tower and whether this suggestion was likely while the finish of the building was certainly important it is submitted that Aesthetics were certainly not the final

00:34:49 Aesthetics were certainly not the final driver in the refurbishment in identifying the priorities for the refurbishment project the TMO engaged with the community and its residents

00:35:00 with the community and its residents these discussions revealed that improvements the internal living conditions could best be achieved by upgrading the communal domestic hot water and central heating systems and by

00:35:11 water and central heating systems and by installing thermal insulation to improve thermal efficiency and fuel economy as well as by installing new windows while the tier most suddenly sought to include residents in the decision-making

00:35:23 include residents in the decision-making processes about the refurbishment and the ways in which it did this were extensively be considered in module 3. the TMO acknowledges that some residents say they did not participate

00:35:35 say they did not participate meaningfully in the discussions surrounding the refurbishment and this acknowledges that the inquiry will consider how else the TMO could and should have achieved meaningful engagement

00:35:47 engagement so one example of the TMO listening to and responding to Resonance concern is when dissatisfaction was expressed during the project about the positioning of the hot water boiler

00:35:58 of the hot water boiler the TMO took these concerns into consideration and adjusted the plan alongside Ryden albeit after some delay

00:36:09 some general submissions the grenful tower fire was a fire unprecedented in post-war Mainland UK history and the causes of it have been shown to be

00:36:20 causes of it have been shown to be complex deep-rooted and deeply troubling although the fire occurred at grenfell Tower it is submitted that in reality the same or a similar fire could have

00:36:31 the same or a similar fire could have occurred at any of the many high-rise buildings across the UK that were clad in acms or other combustible cladding or which had PIR or other combustible

00:36:42 which had PIR or other combustible insulation this was the view of a number of informed commentators from within the social housing sector in the wake of the fire

00:36:52 fire for example David Montague then the chief executive at Allen Q set of the tragedy and so this is a quote it's utterly shocking the thought that it could have been anybody it could have

00:37:03 could have been anybody it could have been anybody in the sector so we submit that such views should not be readily discounted it may be that a fire of the sheer scale and lethal intensity of the one at

00:37:16 and lethal intensity of the one at Granville Tower was always liable to be unique although this may ultimately be a matter of speculation and it is recognized that other cladding fires have not resulted in such a terrible

00:37:27 have not resulted in such a terrible loss of life and so the inquiry will certainly consider whether there were peculiarities at grenful Tower which allowed the fire to spread as quickly and extensively as it did for example

00:37:39 and extensively as it did for example the presence of the architectural Crown which has strongly implicated in the fire's horizontal spread across the building and the fire then burning down other sides of the building

00:37:50 other sides of the building whatever is the case with this urgent investigations following the fire revealed the extent and complexity of what's been referred to in common violence is the cladding crisis

00:38:02 violence is the cladding crisis there was flammable cladding on large numbers of buildings high rise and low rise private and public sector in the immediate aftermath of the fire dangerous cladding was removed from

00:38:14 dangerous cladding was removed from hundreds of buildings and where it could not be removed immediately waking watches were established and indeed are still in place on many buildings even to this day

00:38:24 this day the TMO submits that the inquiry should carefully consider the extent of the wider problem it is submitted that only buying doing this can the inquiry make a properly informed Judgment of the TMO

00:38:37 properly informed Judgment of the TMO has client in this refurbishment product a project

00:38:42 a project so the inquiry is not closely considered the extent to which acms and other flammable materials were present on other blocks across the UK at the time of the fire and therefore the submissions I make on this matter today

00:38:54 submissions I make on this matter today are derived mainly from open public sources and So within the written submissions we have provided links and footnotes in respect of these sources

00:39:06 soon after the fire tests were carried out on numerous blocks and the government announced that every Tower block tested had failed some fire safety tests in respect of its cladding

00:39:18 tests in respect of its cladding in October 2017 up to 60 tower blocks across 25 local authorities a large proportion of which were Council owned or Housing Association were reported to

00:39:30 or Housing Association were reported to have failed such tests a review of records for March 2018 provided by mhclg and collated as part of the building safety program indicated

00:39:42 of the building safety program indicated there were at that time 306 buildings over 18 meters with ACM cladding which did not meet building regulations and presented fire hazards

00:39:54 presented fire hazards online figures for 2019 and 2020 showed a steady increase in the number of buildings over 80 meters that had ACM which should not meet building regulations

00:40:05 regulations on a final tally as of 30th September 2022 the government published figures state that there are a total of 486 Residential Properties over 18 meters

00:40:17 Residential Properties over 18 meters with ACM cladding systems unlike excuse me unlikely to milk to meet building regulations the mhclg commission testing into the

00:40:28 the mhclg commission testing into the burning behaviors of a range of non-acm cladding materials to identify whether there were other types of cladding that burned like the materials present on ground floor Tower

00:40:40 ground floor Tower many buildings were found to have this type of cladding and therefore in March 2020 the dlhc announced a one billion pound Building Safety fund aimed at

00:40:51 pound Building Safety fund aimed at remediating buildings of 18 meters and above which presented a significant risk of Fire

00:40:58 of Fire as of the 30th of September 2022 there have been

00:41:03 have been 2824 private sector applications for government funds from the building safety fund to fix buildings with non-acm problems

00:41:14 non-acm problems so we say this is indicative of the national crisis which has been which has been revealed since the fire so we have not sought to collate figures for buildings internationally but it's

00:41:25 for buildings internationally but it's well known that this is also an international problem in addition the fact that 49 developers which includes numerous well well-established companies such as

00:41:36 well-established companies such as Barrett

00:41:37 Barrett belway Barkley Cress Nicholson galliard homes person and Taylor wimpy to name only a few signed the building safety repairs pledge to remediate life

00:41:48 repairs pledge to remediate life critical fire safety works and buildings over 11 meters which they themselves had played a role in developing or refurbishing across the last 30 years in

00:41:59 refurbishing across the last 30 years in England this also attests the scale of the problem so we say that these figures cannot be ignored when the query when the inquiry assesses the circumstances in which a

00:42:10 assesses the circumstances in which a block managed by the TMO came to be clad in such dangerous materials the sheer scale of the cladding crisis supports the proposition that it could

00:42:22 supports the proposition that it could have been anybody in the sector whether in the light of this it would be wrong to single out the TMO or its employees as being uniquely or egregiously at fault

00:42:33 fault for each building where there was dangerous cladding that needed to be removed there would have been a CDN client likely in a similar position to the TMO

00:42:46 so moving on now to some general submissions about the materials used in the refurbishment of groundford Tower and as you reported in the phase one report the principal reason why gramful

00:42:57 report the principal reason why gramful Tower was so quickly and completely engulfed by fire was because it was clad in an ACN with a polyethylene core without that ready source of fuel without the right source of fuel

00:43:08 without the right source of fuel provided by the acms it seems highly unlikely that there would have been a fire of such lethal intensity once the fire took hold in the ACM

00:43:19 once the fire took hold in the ACM cladding and compartmentation was breached all active and passive fire measures were quickly overwhelmed as they were being called on to perform in an unprecedented situation for which

00:43:31 an unprecedented situation for which they were never designed so the evidence touching on these issues has been painstakingly examined during the inquiry but as the TMO submits that its responsibility for the circumstance

00:43:43 its responsibility for the circumstance in which these acms came to be used is extremely limited it proposes to summarize briefly some of the Salient features of that history and art

00:43:54 features of that history and art so the Rhino Bond 55p rainscreen panel cassette system was tested in France in 2005.

00:44:02 2005. it received a Class E rating under the standard European fire test system where A1 was the best and F the worst it was only in a 2008 report that the Rhino

00:44:13 only in a 2008 report that the Rhino Bond p55 received a Euro Class B rating and this was for the riveted form and not the cassette form this one successful European test in

00:44:25 this one successful European test in 2008 was quickly used to obtain UK certification from the BBA the certificate in question stated that the Rhino Bond p55 panels were to be regarded as having a class zero surface

00:44:39 regarded as having a class zero surface and it is submitted gave the reader of the certificate to think that this included the concept form also sir arconic was happy to rely on the BBA certificate and did so for the next

00:44:51 certificate and did so for the next eight years despite the fact that it knew the cassette form of the product had been rated only class E in 2005 and indeed when retested in 2011

00:45:03 indeed when retested in 2011 2014 and 2015 it received the same e-classification indeed it seems that after 2011 when iconic became definitively aware of

00:45:16 iconic became definitively aware of rhino Bond pe's poor performance and fire it deliberate deliberately targeted countries such as the UK which were not solely working with the European classification system

00:45:29 classification system certification aside our conic was aware of the inherent risks with this cladding from 2007 onwards the inquiry heard that arconic's marketing manager attended a

00:45:41 marketing manager attended a presentation in 2007 which warned of ACM cladding fires but despite this arconic continued to manufacture and Market rhinobong PE telling clients such as the

00:45:54 rhinobong PE telling clients such as the TMO it was able to follow what type of product was being developed and offer the right specification thus when in 2012 and 2013 arconic

00:46:07 thus when in 2012 and 2013 arconic pushed PE 55 in cassette form for use on ground floor Tower and so they did push it knowing this was a high-rise building they were aware that it was wrongly

00:46:18 they were aware that it was wrongly certificated and its use had been implicated in serious fires dealing briefly with the installation news on grandfather the TMA the TMO

00:46:29 news on grandfather the TMA the TMO makes these brief submissions although unsafe cladding was the principal cause of the fire the expert evidence has shown that unsafe insulation including celatex's RS 5000

00:46:40 insulation including celatex's RS 5000 and kingspan's core firm k-15 insulation boards increased the likelihood of a serious fire and the intensity of any fire once it started the inquiry had evidence that 2014

00:46:53 the inquiry had evidence that 2014 testing of celotex RS 5000 was rigged also the bre which conducted the test may or may not have been aware of this sellotex then marketed the product in a

00:47:05 sellotex then marketed the product in a way it accepted and evidence was thoroughly misleading with kingspan k-15 there was a similar story

00:47:13 story the kingsman products used in the refurbishment had failed a fire test in 2007 but nevertheless kingspan marketed it on the basis of a successful test in

00:47:25 it on the basis of a successful test in 2005 however this test related to a product with a different makeup and composition Witnesses from kingspan appeared to accept in evidence that this amounted to deliberately misleading the customer

00:47:38 deliberately misleading the customer with the above in mind with this a mindset it's again alarming that a certificate was then issued by the BBA in 2008 which classified k-15 as class zero with the certificate further

00:47:50 zero with the certificate further stating that the product will not contribute to the development stages of a fire or present a smoke or toxic Hazard k-15 was neither non-combustible nor a material of limited combustibility

00:48:03 nor a material of limited combustibility it seems that even after the fire and indeed the inquires initial findings about the role of the installation it was still necessary for the Secretary of State to serve prohibition notices on

00:48:15 State to serve prohibition notices on kingspan requiring it to see supplying the product and to contact its customers and those in the supply chain to secure its return from the market and use very simply sir had the TMO known or

00:48:28 very simply sir had the TMO known or been made aware by its professional team that the certification for any of the products used in the refurbishment was inaccurate or that the testing of those products was invalid it would certainly

00:48:40 products was invalid it would certainly not have allowed them to be used the TMA will no doubt consider the extent to which it was let down by its own team of professional advisors

00:48:51 own team of professional advisors so findings about the findings after the fire about the prevalence of these products and other buildings is alarming they're in the light of the misselling and mistesting possibly unsurprising

00:49:03 and mistesting possibly unsurprising so the story of how dangerous products came to be used on Granville towers does not end with their certification by the BBA it's necessary also to consider

00:49:14 BBA it's necessary also to consider misconceptions and willful misuse of the UK class zero rating was widely

00:49:25 the UK class zero rating was widely understood to mean principally on the basis of diagram 40 and ADB that a product was suitable without more for use on the outside of buildings taller than 80 meters

00:49:36 than 80 meters although the prevalent view this was not what class 0 meant or should have meant in fact it had nothing to do with the overall combustibility of a given material including the combustibility of

00:49:48 material including the combustibility of the core of a composite such as ACN how was it this dangerous misconception under which much of the construction industry was laboring arose and

00:49:59 industry was laboring arose and persisted

00:50:01 persisted it seems that government certainly played a part in it the evidence the inquiry heard in module 6 suggests suggests that government was aware the class 0 classification was being

00:50:12 class 0 classification was being continuously and consistently misrepresented Barbara Lane said it had degraded over time David Crowder from the BBA said that he did not support Class Heroes of fire

00:50:24 did not support Class Heroes of fire safety test but it was maintained due to political motivations when he shared his concerns with Brian Masters he was told that there were and I quote Brian Martin

00:50:35 that there were and I quote Brian Martin I apologize Brian Martin he was told that there were and I quote industry interests and products that were on the market as a result of achieving class zero that would cease to

00:50:46 achieving class zero that would cease to be on the market if class zeros cease to be a viable option but this state of affairs arose and persisted in England and Wales in plain view of the government was all the more

00:50:58 view of the government was all the more surprising because in 2005 after the garlic caught fire in 1999 Scotland changed its technical guidance to require cladding use on external walls

00:51:09 require cladding use on external walls of high-rise domestic buildings to be constructed on non-combustible products there was no ambiguity with this despite the fact that the Parliamentary select committee said and again I quote we do

00:51:22 committee said and again I quote we do not believe that it should take a serious fire in which many people are killed before reasonable steps are taken towards minimizing the risks and although effective changes were made in

00:51:33 although effective changes were made in Scotland only limited changes were made to ADB and the governments didn't the government did not change the guidance in ADB that class zero materials could be used on the external walls of a

00:51:45 be used on the external walls of a high-rise building moreover the 2009 lacnor rule 43 recommendations which set out a clear case for revisiting regulation on

00:51:56 case for revisiting regulation on cladding on exterior walls including ADB were well known to all but were not acted upon so it was right therefore that DL UHC said in its opening statement the

00:52:09 said in its opening statement the inquiry in Phase 2 module six that and I quote again the department should have done more to take on board the learning and recommendations triggered by other fires including the tragic events at

00:52:20 fires including the tragic events at lachenal house including exploring whether the system was working as intended

00:52:26 intended similarly correspondence from the all-party Parliamentary group on fire safety should have been addressed in a timelier manner with more done to probe the issues raised by them

00:52:37 the issues raised by them so it was also right there for Council for DL UHC to admitting closing submissions to module six that's it DL UHC failed to provide sufficient oversight of a regulatory system which

00:52:50 oversight of a regulatory system which if it had been in place could have prevented the Granville Tower fire was also accepted that deregulation played a part in underpinning a culture in which officials did not properly

00:53:01 in which officials did not properly escalate warnings when they were raised or progress work in response to recommendations and in particular those made by the coroner following the lack and all house fire in 2009

00:53:14 and all house fire in 2009 and so the TMO says the inquiry will have to make a decision on whether the government actually colluded in the dangerously misleading system of selling and classification for this type of

00:53:26 and classification for this type of material

00:53:28 material so as an aside whether in fact it felt the government to stay ahead of changing practice within the construction industry has been questioned by many including Dame Judith Hackett in her independent review of building

00:53:39 independent review of building regulations however whatever the answer to that is the guidance produced by the government was unclear and was widely interpreted to justify the use of

00:53:50 interpreted to justify the use of certain combustible products and circumstances where they were wholly unsuitable so we on behalf of the TMA have spent some time addressing the misselling and

00:54:01 some time addressing the misselling and misclassification of acms and insulation failures by hmm government to get a grip of the regulatory system because it is submitted that this is an important backdrop for consideration of in

00:54:14 backdrop for consideration of in particular the way the TMO acted in the contractual procurement process and management of the projects so as was previously submitted the TMO

00:54:25 so as was previously submitted the TMO will say that it the way that it went about appointing contractors and the pre and post contract phase for the refurbishment was rational and generally acceptable for a non-specialist client

00:54:36 acceptable for a non-specialist client receiving advice on appointments in a design and build contract so the inquiry is well aware of the history of the tier mobile briefly it was a not-for-profit organized not-for-profit Company Incorporated in

00:54:48 not-for-profit Company Incorporated in 1995 under the right to manage legislation whose function was to manage and maintain rbkc's housing stock it had no shareholders but did have

00:55:00 it had no shareholders but did have approximately 5 600 members who were residents of rbkc housing stock was a resident-led organization that in that there was a majority of local tenants and leaseholders on its boards any

00:55:13 and leaseholders on its boards any profit or surpluses were attained by the organization to improve services to residents it was the client for the refurbishment project pursuant to the CDM regulations 2007 and so these

00:55:26 CDM regulations 2007 and so these regulations acknowledge that clients may not themselves be specialists in construction techniques and so are not required to plan or manage the projects themselves while so as you observed it

00:55:38 themselves while so as you observed it was an educated client its key function was nevertheless the management and maintenance of social housing stock where rbkc was landlord in 2011 rbk said advertised through the

00:55:52 in 2011 rbk said advertised through the OG process the tender for a project to build a new Academy and Leisure Center calc on the Lancaster West estate at the base of Granville town the cow project also included the

00:56:03 the cow project also included the construction of 30 residential dwellings this project was authorized and led by rbkc with the TMO playing no role however because rbkc recognized that the residents of granfall tower directly

00:56:15 residents of granfall tower directly affected by the ongoing works on calc because the TMA was able to identify groundford Tower as a major investment priority there were discussions about whether it could be regenerated

00:56:26 whether it could be regenerated alongside the count project for the count project rbkc had procured a team of professional Consultants by accessing a competitive tender and vetting process the project team

00:56:38 vetting process the project team included Studio ears lead consultant Apple yards artelia as cost consultants and employers agent Max Fordham is structural and unemployed and employs agent Max Fordham as Structural

00:56:51 agent Max Fordham as Structural Engineers and Ledbetter group as the principal contractor a decision was taken to utilize the same team or broadly the same not not least because cows calc which was on a far

00:57:02 because cows calc which was on a far greater scale than the Granville Towery version was deemed to be a successful project

00:57:07 project the intended benefit of using the same consultants and contractors was that the works could commence more expeditiously and be more cost efficient the TMO understood that all the appointees for

00:57:19 understood that all the appointees for the count project would be qualified and competent to carry out the refurbishment project at groundfall Tower it was certainly not told otherwise in recognition of the scale of the

00:57:30 in recognition of the scale of the project the TMO established his own project management team to oversee the refurbishment from the client's percept perspective this team included a dedicated project manager

00:57:41 dedicated project manager while the team possessed a general understanding of the construction industry in its legislative framework and of how projects were procured and delivered from the Viewpoint of a client it would only ever have delivered a

00:57:53 it would only ever have delivered a construction project by employing external construction professionals the TMO would not and could not deliver any construction projects itself artelia which was appointed as employers

00:58:05 artelia which was appointed as employers agent advised that the procurement route of the project should be designed and billed

00:58:10 billed a pre-contract professional team whose responsibility was to ensure that all pre-contract works were compliant with applicable legislation codes of practice and building control requirements was

00:58:22 and building control requirements was assembled the tiermost client was not part of the pcpt and relied on the professional team it had appointed for design compliance Studio e was a key part of the pcpt and

00:58:36 Studio e was a key part of the pcpt and was engaged to provide a complete service of works from inception to completion it was appointed to provide full architectural services and was lead consultant lead designer and architect

00:58:48 consultant lead designer and architect as designer the pre-contract Stage Studio e was responsible for compiling the design and specification for The Works which included the windows and the cladding systems

00:59:01 cladding systems so the TMO recognized that concern has been expressed that studio e had never previously undertaken the overclabbing of a residential building and it is accepted that the inquiry will accept this aspect of the evidence with care so

00:59:13 this aspect of the evidence with care so we say that the evidence poor Hyatt has rev is relevant on the point he said it was not unreasonable for practice of the size and experience of Studio e to undertake such a project as long as it

00:59:25 undertake such a project as long as it took appropriate steps to acquire the knowledge to discharge the project safely

00:59:30 safely Ryden was appointed as principal contractor following successful tender and so it's submitted that Ryden II was a rational and suitable appointment at the time given its size its track record

00:59:43 the time given its size its track record and its familiarity with cladding projects

00:59:46 projects pursuant to the design and build contract Ryden was required to carry out the design construction and completion of both the proposed re-cladding and installation of Windows the contract

00:59:57 installation of Windows the contract with ride and specified at the construction and materials used in it complied with all applicable regulations legislation and codes of practice

01:00:08 legislation and codes of practice so um turning to two particular topics of concern about the pre and post-contract procurement phase these particularly arose in the evidence heard in module one they'll be addressed again briefly here firstly what's been

01:00:21 briefly here firstly what's been described in the choirs Peter Madison's offline meeting with Ryden the tiermost submits that whatever the inquiry May conclude about the circumstances in which the meeting

01:00:32 circumstances in which the meeting occurred

01:00:34 occurred even if matters had been approached differently it is unlikely that a different contract would have been appointed as by the time the meeting occurred Ryden had been identified as

01:00:46 occurred Ryden had been identified as the preferred bidder through Pi through price and quality moreover even if a different contractor had been appointed it's highly unlikely that different decisions would have been taken about

01:00:58 decisions would have been taken about the materials value engineering the inquiry heard that there was value engineering but the between the TMO and Ryden prior to Ryden being appointed as principal contractor in March 2014.

01:01:12 principal contractor in March 2014. while it is acknowledged that Ryden was the only tendering contractor offered the opportunity to Value engineer this does not mean that the value engineering was wrong per se in fact so it was

01:01:23 was wrong per se in fact so it was common for Value engineering to occur in large-scale large-scale construction projects of this sort especially ones involving public money and of course an organization such as

01:01:35 and of course an organization such as the TMO had a duty to use public money efficiently it is recognized that the choice of cladding formed part of the value Engineering Process and in this context

01:01:46 Engineering Process and in this context the TMO invites the inquiry to consider the prospect of using cladding other than zinc had already been raised in 2013 by another contractor Ledbetter and

01:01:57 2013 by another contractor Ledbetter and this was prior to Peter Madison joining the project in fact as part of the original MBS specification bidders had been asked to price for alternative rain screen

01:02:09 price for alternative rain screen cladding to zinc therefore the possibility that cladding other than zinc would be used had Arisen before the value Engineering Process um was undertaken moreover Simon

01:02:20 um was undertaken moreover Simon Lawrence from Ryder was argue in favor of using acms before the value engineering exercise had been embarked upon so too apparent was Mark Harris of Harley facades in the meeting on the

01:02:32 Harley facades in the meeting on the 27th of September 2013 at the Hayes Galleria with Studio e in the light of this the tiermost submits the inquiry should ask itself whether even if value engineering had

01:02:44 whether even if value engineering had not occurred a different outcome with regard with regard to cladding would have been reached so two further issues the client heard it that the inquiry had evidence on whether the TMO should have appointed a

01:02:56 whether the TMO should have appointed a client design advisor whether it was appropriate for the TMO to take on the role itself the TMO reiterates its closing submissions to modules one and two where it was said that the CDM regulations did

01:03:08 it was said that the CDM regulations did not require a client design advisor to be appointed and even if one had been appointed it is highly unlikely it is submitted that this would have made a difference as selection of materials The

01:03:20 difference as selection of materials The Wider design process or the quality of workmanship especially in the life of what the inquiry heard about the Miss selling and misregulations surrounding acms

01:03:30 acms another issue is whether when the CDM regulations 2015 came in the TMO should have assumed the newly created role of principal designer so this was also addressed in the tmo's closing

01:03:42 addressed in the tmo's closing submissions modules one and two and as was stated there stated there the TMO is not advised until late in the day that the new legislation required a principal designer to be appointed and it only

01:03:54 designer to be appointed and it only took on the role when all others refused it in the in any event by the time Claire Williams took on the role she was advised that the design was fundamentally complete and so even if

01:04:06 fundamentally complete and so even if the inquiry does conclude that the TMO should not have assumed that the role there is little to suggest there is a suggest that by doing so it cause events to occur which would not

01:04:17 cause events to occur which would not otherwise have occurred or failed to prevent prevent events which should not have occurred so more generally whatever input the TMO had into the choice of materials used on

01:04:29 had into the choice of materials used on ground floor Tower at no point was it ever told by its experienced professional team that the material was finally selected for use were inappropriate still less dangerous

01:04:40 inappropriate still less dangerous in the light of all the inquiries heard about the tangled web of cynical corporate deception long-standing and deep-rooted misconceptions about the key classification for cladding products

01:04:51 classification for cladding products used on tower blocks above 18 meters and a regulatory framework that allowed such dangerous misconception to persist it is submitted that it would be unfair for the inquiry to conclude that the TMO

01:05:03 the inquiry to conclude that the TMO should in some way unilaterally have realized that acms were inappropriate for use during the gravel Tower refurbishment this is something it's submitted the

01:05:14 this is something it's submitted the inquiry should bear in mind when looking at Claire Williams lack and all moment when considering whether this was a missed opportunity to lose to use cladding other than flammable acms the

01:05:25 cladding other than flammable acms the inquiry should recognize that the decision to use and was reached approved of or acquiesced in by a number of contractors all of whom either had or purported to have expertise in the

01:05:37 purported to have expertise in the selection of materials so two more discrete masses before I come to my last topic the role of X over first

01:05:44 first there's strong evidence to show that X over did not complete important fire safety work on the refurbishment and in doing so failed in its contractual responsibilities EXO is maintaining that

01:05:56 responsibilities EXO is maintaining that it was not retained by ride and as does little to explain why it failed to complete the work it should have completed which would have included an assessment of the external wall and to

01:06:07 assessment of the external wall and to advise properly on the smoke control system

01:06:10 system the project was also signed off by rbkc building controllers being compliant with the prevailing building standards whether or not this should have happened as a mass the inquiry will examine with

01:06:21 as a mass the inquiry will examine with with care including whether there was an over-reliance on building control and whether the workload of John Hoban was to onerous however whatever the inquiry

01:06:32 to onerous however whatever the inquiry concludes in relation to this it's respectfully submitted

01:06:37 it's respected something that the TMO was entitled to derive comfort and Assurance from building control sign-off and approval certainly against the backdrop of a project which had been carried out by

01:06:48 project which had been carried out by professionals including those in the cladding industry there was nothing following that approval to put the team on no tml notice that things have been done in an unsafe or dangerous way

01:07:00 done in an unsafe or dangerous way so turning out the last Topic in which the TMO will make submissions the way in which the active and passive fire measures at groundwater Tower performed on the night including the way in which the tierno procured and managed the

01:07:11 the tierno procured and managed the contract for these also the appointment and retention of Carl Stokes and peeps the TMO reiterates the general submission it has made previously that

01:07:22 submission it has made previously that the active and passive fire measures were never designed to operate in a fire of this magnitude and so were quickly overwhelmed it's submitted the Inquirer will have to Grapple with the issues of

01:07:34 will have to Grapple with the issues of causation that arise from this fact regarding the buildup of smoke in the communal lobbies the TMO acknowledges that inquiry has heard evidence the buildup of smoke and the communal lobbies was rapid and represented a key

01:07:47 lobbies was rapid and represented a key factor in the ability of residents to escape it is accepted the inquiry has heard evidence suggesting that this rapid buildup may have been connected with the resistance of some of the fire doors in place and the absence of

01:07:58 doors in place and the absence of self-closing devices on on some of the flat front doors regarding the first of these the inquiry heard evidence in module 3 that the TMO entered into a contract with Mance master door to replace doors across the

01:08:11 master door to replace doors across the housing stock it managed it appears that Mance likely did not fit doors but had the necessary resistance to fire in the way it had been contracted to do The

01:08:22 way it had been contracted to do The Inquirer will have to assess the circumstances surrounding the discharge of the contract TMO made detailed submissions on this since closing to module 3 and there will certainly not be repeated here so looking at the topic from a wider

01:08:34 so looking at the topic from a wider perspective there is evidence to suggest that fire doors with with inadequate levels of fire resistance was a widespread problem in the industry we're certainly not merely confined to the TMO

01:08:46 certainly not merely confined to the TMO or gramful Tower testing carried out by the government in 2018 showed that fire door was made by five different suppliers failed fire safety tests and were withdrawn from the market the then

01:08:58 were withdrawn from the market the then Community secretary James brokenshire confirmed at the time that he had and I quote enough evidence to suggest that there is a broader issue across the fire door Market

01:09:09 door Market in March 2018 the government told Parliament that there was no evidence of a systemic issue with fire doors however following that Mance master door removed two doors two types of doors from sale

01:09:21 two doors two types of doors from sale as they did not meet the standard when tested and it is reported of contacted social land social housing landlords who are customers to inform them of the issue

01:09:33 issue in July 2018 mhclg wrote to building control bodies alerting them to the need to check the performance of fire doors to ensure the requirements of building regulations

01:09:44 requirements of building regulations were met

01:09:45 were met by November 2018 government was undertaking an investigation Into the Fire door industry following concerns about the consistency of flat front entrance fire doors against the required

01:09:57 entrance fire doors against the required performance standard

01:10:00 so concerning the way in which the TMO sought to ensure that door closes once fitted were kept in good repair then Quarry heard detailed evidence on this including how the TMO was told after the

01:10:11 including how the TMO was told after the Adair Tower of fire that it should take steps to satisfy itself the door closes across its estate were functioning correctly

01:10:19 correctly the TMO accepts The Inquirer look carefully the inquiry will look carefully at how it's sought to implement the requirements of the deficiency notice issued in respect to the Dare Tower and how it dealt with the

01:10:30 the Dare Tower and how it dealt with the issue of fire door closers of door closers prior to this detailed submissions on on this topic were made in the tmo's closing submissions module 3 and again they will not be repeated here

01:10:42 not be repeated here suffice it to say that ensuring door closers was were fitted and kept in a good condition in a good condition was an issue affecting the whole social Housing Industry Janice Ray said that

01:10:54 Housing Industry Janice Ray said that when she made inquires of others within the social housing sector none really had a solution of ready or widespread application that there was a widespread problem with

01:11:06 that there was a widespread problem with the maintenance of door closes is Apparent from what was said by the door and hardware Federation a trade Association for companies associated with locks and buildings hardware and door set door sets DHS general manager

01:11:20 door set door sets DHS general manager and secretary secretary state that it is too often the case that door closers are incorrectly specified or badly installed and a greater understanding of how to comply with the relevant standards was

01:11:31 comply with the relevant standards was needed he also said that he also said that a lack of Maintenance often exacerbates the problem

01:11:40 the difficulties isn't drafting definitive advice for those involved in building safeties illustrated by for example the fact in January 2020 the government published Building Safety

01:11:51 government published Building Safety advice for building owners including advice and fire doors but the publication was withdrawn on the 10th of January 2022 because it was said to have been wrongly interpreted and to have

01:12:03 been wrongly interpreted and to have driven a too cautious approach to building safety going beyond what the government considered necessary the fire safety England regulations 2022 will make it a legal requirement from

01:12:14 will make it a legal requirement from the 23rd of January 2023 for responsible persons for all multio multi-occupied residential buildings in England with stories over 11 meters high

01:12:25 England with stories over 11 meters high to one undertake quarterly checks of all fire doors including self-closing devices in the common parts and two undertake on a best Endeavor basis annual checks of all flat entrance doors

01:12:39 annual checks of all flat entrance doors including self-closing device that lead onto a building's common parts the regulations will also require responsible will also require responsible persons to provide residents of all multi-occupied residential

01:12:51 of all multi-occupied residential buildings with information on the importance of fire doors to a building's fire safety so it's a matter for the inquiry but it's submitted that the fact that such legislation was enacted

01:13:03 legislation was enacted attests to an existing lack of clarity a lack of clarity around when and how door closers should be checked and the need to make sure that the general the public appreciate their importance

01:13:16 appreciate their importance but the fact that Duty holders are required only to use best Endeavors to check flat entrance doors speaks speaks to the difficulties in gaining access to

01:13:27 to the difficulties in gaining access to domestic Flats so touching briefly on the lifts of grenfell Tower

01:13:33 when the the lifts were refurbished the TMO received expert advice on how to ensure it met the relevant standards and the inquiry will consider the extent of the advice given whether the TMO

01:13:46 the advice given whether the TMO reasonably relied on the appliance further after the refurbishment there were contracts in place for maintenance of the lifts and the tmo's expectations that the lifts were being properly maintained inquiry will consider the way

01:13:58 maintained inquiry will consider the way in which the TMO managed these contracts the inquiry will also draw conclusions on the evidence it heard regarding the ability of the nfb to take control of the the lift using the fireman switch

01:14:09 the the lift using the fireman switch during the fire the tiermost submits that the inquiry had evidence that it did have in place subcontractors whom it could reasonably have expected to maintain the lifts and their Associated switches

01:14:22 their Associated switches regarding the smoke control system the inquiry will need to consider how the system performed on the night of the fire when doing this it will need to keep in mind as has been said that it was never designed to deal with the

01:14:34 was never designed to deal with the quantity or smoke in the ground floor Tower of fire in this regard the inquiry had evidence from Simon lay who opined that the system operated as intended and that it's likely it operated Beyond its

01:14:46 that it's likely it operated Beyond its expected parameters despite the failure of other Provisions that it relied on

01:14:53 so regarding Carl Stokes and briefly it submitted that the TMO was entitled to conclude Carl Stokes was a competent fire risk assessor and despite some parts of his reports there was nothing

01:15:05 parts of his reports there was nothing about his overall performance that should have caused the TMO to think his Services should have been dispensed with altogether that the TMO was entitled to conclude this was the that conclude this was the

01:15:16 this was the that conclude this was the case was confirmed by Colin Todd the expert commissioned by the inquiry he said that Carl Stokes reports were of a reasonable quality and would not have given those engagement to include that

01:15:28 given those engagement to include that he was not capable of Performing the role

01:15:31 role since the fire at gramful Tower both the fire safety act 2021 and the fire fire safety England regulations 2022 have been drafted which now formalized for the first time the role of a fire risk

01:15:44 the first time the role of a fire risk assessor the fire safety act 2021 amends the fire safety order 2005 to clarify that in buildings with two or more sets of domestic premises the fire safety order 2005 does apply to the structure

01:15:58 order 2005 does apply to the structure and external walls of the building including cladding balconies and windows and to all doors between the domestic premises and the common parts prior to the fire certainly the view of

01:16:09 prior to the fire certainly the view of many authoritative commentators and practitioners that it did and again so the TMO says the fact that the government that it did not I'm sorry again the fact that government seemed fit to legislate on the topic tends to

01:16:22 fit to legislate on the topic tends to suggest a previous lack of clarity around it at the very least regarding peeps the inquiry heard that the TMO did not have a system for completing peeps for disabled residents

01:16:33 completing peeps for disabled residents at grenfell Tower that none was in fact completed

01:16:37 completed in not completing peeps the TMO is not acting inconsistently with the practice of other orgas organizations in a similar position at the time and indeed today and so the TMO refutes the

01:16:50 today and so the TMO refutes the suggestion that it did not care for disabled people decisions about which floor disabled people were housed and were not made by the TMO but by rbkc or although the TMA was aware of persons

01:17:02 although the TMA was aware of persons with disabilities it believed that the compartmentation and the state strategy was a sound one

01:17:12 in May 2022 the government announced proposal that went counter the inquiry sorry I'll start that against that in May 2022 the government announced proposals that went counter to your

01:17:23 proposals that went counter to your recommendations for peeps deeming them impractical and not proportionate so that fact alone attests the difficulties at least surrounding the issue of peeps for disabled people in high-rise

01:17:35 for disabled people in high-rise buildings

01:17:36 buildings though the topic was a subject of government of a government consultation which recently published the responses it received is again now the subject of a further consultation despite the

01:17:47 a further consultation despite the inquiry's recommendations the existence of the current debate demonstrates the complexity around seeking a resolution to the issue TMA was certainly not unique in its approach towards Peeps and social

01:17:58 approach towards Peeps and social housing and the difficulties encountered in resolving how disabled people could safely evacuate a high rise building as submitted this the fact that this remains unresolved should be kept in

01:18:10 remains unresolved should be kept in Mind by the inquiry when considering the tmo's conduct to the fire conduct price the fire regarding peeps so in conclusion the TMO recognized that

01:18:22 so in conclusion the TMO recognized that its conduct and the conducts of its staff will be carefully assessed and analyzed by the inquiry respectfully invites inquiries to take into account all of the submissions made above and now when analyzing its conduct

01:18:35 above and now when analyzing its conduct and that of its staff it is submitted that in general time in general terms the inquiry would be entitled to conclude the TMO acted reasonably within the limits of its

01:18:47 reasonably within the limits of its roles client on this design and build project and its social housing professional staff acted conscientiously and in good faith the TMO was after all a non-specialist

01:18:59 the TMO was after all a non-specialist body which was entitled to rely on the expertise of its specialist contractors particularly when taking advice on the material should be the materials to be used so also the inquiry should not

01:19:11 used so also the inquiry should not Overlook or underplay The Wider societal and systemic issues that the TMO has sought to identify in its various submissions and so and should we submit consider the tmo's conduct and

01:19:24 consider the tmo's conduct and performance in the light of these TMO also respectfully suggests that the inquiry should not Overlook the fact that it has been necessary to introduce substantial legislative changes in the

01:19:36 substantial legislative changes in the wake of the ground floor Tower fire partly as a result of the inquirizone findings to date so none of these submissions should detract from what was said at the outset that the TMO supports the aims of this

01:19:49 that the TMO supports the aims of this inquiry and it continues to express its sincere condolences but bereaved and hopes that the findings recommendations and implementation of those recommendations provide the breed with

01:20:00 recommendations provide the breed with some comfort in the years to come and so I'm finished there can I can I apologize for going 10 minutes over my allotted time well I don't think you've gone over too badly given the fact that

01:20:13 gone over too badly given the fact that we had a bit of a hiccup at the beginning so thank you very much Mr Edgar us I'm glad we were able to hear you from Birmingham thank you thank you very much

01:20:22 very much the uh next statement is going to be made by Miss uh and stud Kings Council on behalf of the mayor of London so the study I think the housekeeping has been

01:20:33 study I think the housekeeping has been done and we're ready to hear you thank you thank you very much sir so can I start by making some intera into introductory remarks and then I'm

01:20:44 into introductory remarks and then I'm going to deal with seven topics which are featured in the evidence in which the mayor considers are important considerations for your phase two report by way of introduction the mayor would

01:20:57 by way of introduction the mayor would like to start his final remarks to this inquiry by paying tribute to the bereaved survivors and residents who notwithstanding the length of this inquiry and the distressing nature of

01:21:09 inquiry and the distressing nature of much of the evidence called before it have honored themselves and the deceased by the dignity the strength and the composure that they have shown

01:21:21 composure that they have shown at the center of this lengthy inquiry is the tragic loss of life of 72 individuals fittingly the inquiry began with the commemorations in respect of each one of

01:21:33 commemorations in respect of each one of them and concluded with drawing together the circumstances in which each one died the preparation of that evidence must have been harrowing in the extreme

01:21:45 have been harrowing in the extreme those who mourn a loved one and those bereaved survivors and residents who've suffered so profoundly since the fire on the 14th of June 2017.

01:21:56 the 14th of June 2017. have ensured that those who died have meant remained Central to this inquiry notwithstanding the inevitable re-traumatizing impact that the whole

01:22:07 re-traumatizing impact that the whole process must have had on them some have attended these proceedings in person others have attended remotely but all of them have shown bravery and

01:22:18 but all of them have shown bravery and courage and have sought to ensure that those who died have had their voices heard over the half decade since the tragedy

01:22:27 tragedy the mayor is aware of how difficult this inquiry has been for them and how difficult their lives will continue to be when this inquiry is over he knows that the wait for justice has

01:22:39 he knows that the wait for justice has been too long now that the evidential hearings have come to an end the mayor seeks to explore some overarching themes that are featured in the course of phase two

01:22:51 featured in the course of phase two and to highlight topics that are likely to form part of his submission on recommendations those recommendations and the implementation of them will be fundamental to ensuring that the

01:23:04 will be fundamental to ensuring that the Grenville Tower of fire marks a turning point in building safety

01:23:11 does turning to deal with the recommendations and their implementation in his terms of reference user concluded by saying that you would report your findings to the Prime Minister as soon

01:23:24 findings to the Prime Minister as soon as possible and would make recommendations in 2017 in its report how public inquiries can lead to change The Institute of government found that

01:23:37 The Institute of government found that of the 68 public inquiries that had taken place since 1990 only six had received full scrutiny by a select committee to hold the government to account for what progress had been made

01:23:49 account for what progress had been made regarding those recommendations it further concluded that there was no firm procedure for holding the government to account for promises made in the aftermath of inquiries the

01:24:02 in the aftermath of inquiries the implementation of recommendations is patchy and in some cases repeat incidents have occurred and there is no system for allowing inquiries to build on the learning of their predecessors

01:24:15 on the learning of their predecessors in the course of this inquiry it has become clear that the lessons of the lachenal house fire for example had not been learned in spite of the recommendations from the coroner and

01:24:27 recommendations from the coroner and that some of those recommendations may have impacted on the tragic events of the 14th of June 2017. overwhelmingly the bereaved survivors

01:24:39 overwhelmingly the bereaved survivors and residents need to be reassured that this inquiry will make recommendations to prevent future loss of life in similar circumstances they deserve robust and enforceable

01:24:51 they deserve robust and enforceable recommendations to give them some solace in the knowledge that others will not have to suffer in the way that they have

01:25:00 thus far however action and change at a national level has been conspicuously slow or absent notwithstanding your recommendations in

01:25:12 notwithstanding your recommendations in your phase one report the response from government building developers and owners has felt and woefully short of what the bereaved survivors and residents had every right to expect

01:25:25 residents had every right to expect while the London fire brigade has completed 90 of the recommendations directed at the service in the phase one report

01:25:33 report the government has not yet implemented any of the recommendations it is responsible for undertaking nearly three years after they were made

01:25:44 years after they were made in addition there remain too many residents in London and across the country living in fear in high-rise buildings that are covered in dangerous flammable cladding

01:25:56 flammable cladding the matter observes also that the designs for buildings are still being submitted with critical safety failings the unavoidable reality of the evidence

01:26:09 the unavoidable reality of the evidence through phase two is that it has demonstrated a reluctance by government and Industry to learn and instigate change following previous fires

01:26:21 fires evidence heard about the response to the lacknell housing quests showed missed opportunities that failed to prevent a fire such as the one at Grenville Tower occurring

01:26:33 occurring as the mayor set out in his closings for modules one and two this is an opportunity to make real and substantial change

01:26:42 change the inquiry has heard about missed opportunities in the past and this inquiry was not be consigned to history as another one across the industry as a whole there has

01:26:53 across the industry as a whole there has to be a culture of safety and accountability in construction the safety of the building and its residents and visitors must be Paramount and risk ownership

01:27:04 must be Paramount and risk ownership must remain the responsibility of every organization involved with a project

01:27:12 as you heard in the course of phase 2 module 6-1 prior to the refurbishment at Grenville Tower

01:27:19 Tower the bre had testing data demonstrating the materials that were known to be compostable were being used on high-rise buildings

01:27:28 buildings there had been additional warnings from industry to government that the regulations were not clear was subject to differing interpretation and were compromising safety

01:27:39 and were compromising safety yet nothing was done to effectively act upon those concerns or to heed the warnings

01:27:46 warnings the failure to act on this information was a further missed opportunity to prevent this fire as the mayor highlighted in a letter to the then prime minister in June 2022

01:27:59 the then prime minister in June 2022 what is the point of inquest and inquiries if the recommendations and learning that evolved from them is simply going to be ignored the inquiry should be concerned about

01:28:10 the inquiry should be concerned about the slow response of government to the recommendations made in the phase one report and troubled by its rejection of the recommendation that would require owners of high-rise Flats to prepare

01:28:22 owners of high-rise Flats to prepare peeps evacuation plans for disabled residents

01:28:27 residents as the inquiry is aware 41 of those who died in the fire were disabled and not one had a peep the fact that those affected have felt

01:28:38 the fact that those affected have felt compelled to seek redress through the courts is a matter of the utmost concern

01:28:45 the independent charity inquest has for 15 years been calling for the establishment of a national oversight mechanism

01:28:52 mechanism an arms-length public body with a duty to collate analyze and monitor recommendations arising from post-death investigations and their implementation

01:29:04 investigations and their implementation the mayor reiterates his support for the establishment of such a body it is essential that the Grenville Tower inquiry recommendations are neither ignored nor rejected without careful

01:29:17 ignored nor rejected without careful rationale

01:29:18 rationale the mayor would invite the inquiry to recommend to the Prime Minister as part of his report that at the very least a body or system is set up to monitor the progress of the recommendations within

01:29:30 progress of the recommendations within this inquiry reporting annually to Parliament perhaps symbolically on the 14th of June the progress made on the recommendations and updates about their work on Fire and

01:29:43 and updates about their work on Fire and Building Safety overall this should be followed by a parliamentary debate on the report I turn now to deal with the seven topics

01:29:54 I turn now to deal with the seven topics in addition to the issue of recommendations and their implementation the mayor considers that there have been overarching themes that have crossed modules and upon which your report

01:30:06 modules and upon which your report should make consideration first of all the institutional indifference to residents of Grenville Tower and the surrounding buildings

01:30:18 Tower and the surrounding buildings secondly discrimination thirdly the lack of Professional Training competence and skills within the professions fourthly the issue of profit before

01:30:30 fourthly the issue of profit before safety

01:30:32 safety fifthly deregulation austerity and cuts sixth the absence of rigor Independence and transparency in testing and certification

01:30:44 certification and seven the lack of accountability

01:30:50 I turn first to deal with institutional indifference to the residents in modules 3 and 4 particularly the inquiry heard evidence of the treatment of the residents of Granville

01:31:01 treatment of the residents of Granville Tower and its surrounding blocks both during the refurbishment of the building and in the aftermath of the fire the attitude of rbkc and the TMO made

01:31:14 the attitude of rbkc and the TMO made residents feel like second-class citizens a nuisance troublemakers who should take what they were given and be grateful this was wholly unacceptable

01:31:26 this was wholly unacceptable rather than any appreciation that residents wanted to feel safe in their homes

01:31:31 homes there was a total indifference to their needs

01:31:34 needs it was the tmo's job to have regard to those needs and concerns as Mr Define wrote in his statement I never believed that the TMO was capable

01:31:45 never believed that the TMO was capable of keeping residents safe the underlying reasons for this lie in the culture of governance that prevailed and because the Personnel held Prejudice views about how residents should behave

01:31:58 views about how residents should behave essentially to be thankful for their services or effectively be damned they're dealing with me were institutional but institutionally biased

01:32:09 institutional but institutionally biased and in many instances animated by individual prejudice in their eyes I was stigmatized as a troublemaker

01:32:20 having heard the evidence from the bereaved survivors and residents in modules three and four the attitude so eloquently described by Mr defune was clearly not confined to him

01:32:33 clearly not confined to him nor to those in the Granville Action Group

01:32:36 Group or to the small minority of perceived troublemakers identified by the witnesses from Ryden and the TMO in the course of their evidence

01:32:48 the the inquiry has heard evidence on multiple occasions that the tenants were treated as second-class Citizens with the concerns that they raise being ignored or dismissed while the focus

01:33:00 ignored or dismissed while the focus fell on the and I quote Rebel residence and troublemakers and how to undermine rather than resolve their concerns driven as they were to publicly record

01:33:13 driven as they were to publicly record what was happening by setting up the Grenville Action Group blog they were threatened then with libel proceedings by the TMO and the blog was blocked so the staff were unable to view

01:33:24 blocked so the staff were unable to view the resident's complaints it is against that background that failures in provision of support in the aftermath of the fire had to be viewed

01:33:35 aftermath of the fire had to be viewed once again the focus was not on the needs and concerns of those displaced but on preventing public disorder on policing and on avoiding protest making

01:33:47 policing and on avoiding protest making the bereaved survivors and residents feel criminalized wholly unsupported and alone

01:33:53 alone the phase two report needs to record in Stark terms the experience of these residents

01:34:01 residents they are unfortunately not alone the culture of complaints by social housing tenants being dismissed ignored and repairs not acted upon for months unfortunately seems to be commonly

01:34:13 unfortunately seems to be commonly reported

01:34:17 I turned to deal with discrimination in answer to those who invited the chairman to expand his terms of reference to consider whether factors such as social background and race

01:34:28 such as social background and race played a significant role in the Grenville Tower fire the inquiry issued a public statement making it clear and I quote that although the chairman shared the

01:34:39 although the chairman shared the concerns of those who felt these were important questions which required urgent examination on careful reflection he came to the conclusion when recommending the

01:34:50 conclusion when recommending the inquiries terms of reference that the inquiry was not the best way to answer them however if in the course of its investigation the panel finds that factors of that kind played a part in

01:35:01 factors of that kind played a part in any of the decisions under consideration it will make that clear in its report now at the conclusion of the evidence it is important that the inquiry makes good

01:35:12 is important that the inquiry makes good that reassurance as others have made clear previously discrimination is the elephant in the room

01:35:20 room as demonstrated in the relationship between rbkc the TMO and the tenants both before and after the fire issues have institutionalized discrimination

01:35:32 have institutionalized discrimination have Arisen in so many different ways that they certainly warrant inclusion in your Phase 2 report I tend to just look at a few examples

01:35:44 I tend to just look at a few examples the inquiry heard evidence that disabled residents were housed on highest floors without any discussion or plans about what to do in an emergency

01:35:55 what to do in an emergency government guidance written by Colin Todd advised that peeps were not needed in general residential housing and yet 41 percent of those who perished were disabled

01:36:06 disabled disabled residents needs were not given adequate consideration when it came to emergency rehousing after the fire and you heard painful evidence from survivors in relation to the effect of

01:36:19 survivors in relation to the effect of those failures sir disabled residents have been marginalized and treated as though their lives are inferior the government's rejection of the phase

01:36:30 the government's rejection of the phase one recommendation regarding peeps only adds to that sense of marginalization the mayor endorses the emphatic plea from the bsrs outlined by Mr Friedman on

01:36:41 from the bsrs outlined by Mr Friedman on Monday that this inquiry must leave the government in no doubt that their current intransigent position is wholly unacceptable in the light of the

01:36:52 unacceptable in the light of the evidence heard here and that an urgent interim report on this issue is essential in order to immediately address the increased risk to disabled residents seeking to

01:37:03 to disabled residents seeking to evacuate in the event of a fire

01:37:08 the evidence also supports the concern that race played a part in the issues under consideration and warrants inclusion in your inquiry report the inquiry is aware that a significant

01:37:21 the inquiry is aware that a significant proportion of the bereaved survivors and residents in this case and the deceased were black Asian or minority ethnic the weight of the evidence called before the inquiry reveals discrimination at an

01:37:35 the inquiry reveals discrimination at an elementary and obvious level so as to Warrant inclusion for example not considering that information in relation to the refurbishment was available in other languages for

01:37:48 was available in other languages for those with limited English fire safety information only being provided in the building in English Additionally the inquiry heard in module

01:37:59 Additionally the inquiry heard in module 3 that the manipulation of the complaint system disgraceful as it was on its own also discriminated against those who were unable to confidently register a

01:38:10 were unable to confidently register a written complaint in English the Discrimination that had existed before the fire translated to the response after the fire

01:38:21 response after the fire compare and contrast the total lack of consideration of protected characteristics and cultural requirements from rbkc and the TMO in relation to unsuitable meal provision

01:38:32 in relation to unsuitable meal provision and accommodation with the altogether opposite approach of Mr Mark Sims and his volunteers from the rugby Portobello Trust who assisted in organizing a street

01:38:44 who assisted in organizing a street iftar so people could break fast and pray together in their most difficult times

01:38:50 times the state authorities appear to be more concerned with policing those who'd been displaced in order to prevent a perceived risk of public disorder rather than ensuring a safe place accommodating

01:39:03 than ensuring a safe place accommodating their needs and providing as much comfort as could be afforded to them in those Desperate Hours the evidence is so glaring and obvious and the failure is so Elementary that it

01:39:16 and the failure is so Elementary that it is clearly an issue on which the inquiry should now be considering including in its report in order to fulfill that undertaking that you Mr chairman gave so

01:39:28 undertaking that you Mr chairman gave so long ago

01:39:31 I turned to deal with lack of Professional Training competence and skills

01:39:36 skills the evidence in phase two has displayed an alarming lack of training competent and skills in the professional industries that were engaged with the Grenville Tower refurbishment

01:39:48 Grenville Tower refurbishment just by way of example as there are two numerous to list Studio e were under qualified to perform the tasks which they had been contracted to perform and were aware that the

01:39:59 to perform and were aware that the proper procurement process would have Illustrated their lack of experience X over's existing fire safety strategy was wholly inadequate for any relevant purpose for which it was required

01:40:11 purpose for which it was required and Carl Stokes who in April 2016 fire risk assessment wrote that new external planning has been fitted to this building approved and accepted the

01:40:22 building approved and accepted the fixing system and cladding used when he had not even seen any building control documentation or any other independent information his opinion was based on an informal

01:40:34 his opinion was based on an informal conversation with a representative from Ryden and a conversation he had with TMO Barbara Lane described it as professionally Reckless overlaid on that professional Reckless

01:40:47 overlaid on that professional Reckless the inquiry is heard about a cladding industry that relied upon aggressive marketing and was not cowed by the catastrophe catastrophic testing conducted by the bre

01:40:58 conducted by the bre ath that was on the contrary prepared to manipulate the testing ensuring it was over engineered to achieve a path serious consideration must be given to

01:41:09 serious consideration must be given to how this can be rectified by the introduction of clear Professional Standards mandatory requirements of knowledge and expertise and ongoing compulsory training

01:41:20 compulsory training the current skill shortage across industry which affects also the London fire brigade as well as other organizations is a cause for real concern and must be addressed

01:41:31 concern and must be addressed failure to do so undermines any positive changes introduced through the building safety act and the fire safety act profits before safety

01:41:43 profits before safety as the mayor indicated in his closings to modules two one and two of phase two in the course of the refurbishment of the Grenville Tower there appears to have been a primary focus on profit from

01:41:55 have been a primary focus on profit from the contractors and on low cost from the TMO rather than any accountability or concern for risk and safety to the residents

01:42:05 residents none of the basic checks for fire performance were carried out by the design team nor picked up by any other organization including the TMO the evidence that the inquiry revealed a

01:42:16 the evidence that the inquiry revealed a total absence of risk ownership by those who should who should have been expected to have the safety of residents at the heart of the refurbishment the evidence has pointed to a culture in

01:42:28 the evidence has pointed to a culture in the construction industry in which profits are pursued at the expense of Public Safety there are again many examples of this including a willingness of Ryden to

01:42:39 including a willingness of Ryden to pocket a substantial part of the two hundred thousand pound saving by using ACM cladding notwithstanding the greater fire risk

01:42:48 fire risk Additionally the aggressive marketing adopted by the manufacturers seeking to conceal or manipulate testing to achieve better sales on top of that they then threatened organizations who questioned them with

01:43:00 organizations who questioned them with legal action and while loved ones were desperately searching for news of their relatives they attempted to Lobby government to protect their own commercial interests the inquiry report needs to set out

01:43:12 the inquiry report needs to set out clearly sir the unconscionable behavior of the industry illustrating the race for profit where the corresponding disregard for Public Safety that appears to have become embedded in this broken

01:43:24 to have become embedded in this broken system

01:43:28 deregulation austerity and cuts in the later part of phase two the inquiry heard evidence about the barriers that deregulation placed on the ability of departments to amend

01:43:40 ability of departments to amend regulations which had been public which had a public safety impact Anthony Byrd a civil servant in the then dclg told you that the drive to

01:43:51 dclg told you that the drive to deregulate resulted in spending an inordinate amount of time looking at how we could deregulate while Brian Martin said ministers were very focused on avoiding anything that might impact on

01:44:04 avoiding anything that might impact on the economy in a negative way this clearly had an impact on the review of the ABD and the ability to action any significant change in the aftermath of

01:44:15 significant change in the aftermath of lacknell house in addition and undoubtedly the policy of austerity has contributed to a culture in which some state employees see their role to act as Gatekeepers for

01:44:29 see their role to act as Gatekeepers for the meager service provision available rather than as public servants whose role it is to act in the public interest in line with the seven principles of public life state employees should act

01:44:42 public life state employees should act slowly in terms of the public interest and must act and take decisions impartially fairly and on Merit using the best evidence and without discrimination or bias

01:44:54 discrimination or bias the inquiry has heard considerable evidence to illustrate that those principles were not being acted upon by rbkc and the TMO in the course of this refurbishment or in the aftermath of the

01:45:06 refurbishment or in the aftermath of the fire

01:45:08 fire the deregulation agenda coupled with austerity and cuts to Public Services was a dangerous combination the inquiry had evidence that between 2013 and 2017 the rbkc building Control

01:45:22 2013 and 2017 the rbkc building Control Department had lost 10 surveyors who had 230 years experience between them and were replaced by one graduate Mr Hoban when he gave evidence before

01:45:33 Mr Hoban when he gave evidence before you demonstrated the toll that this had had on his ability to do the job he wanted to be able to do the consequences of what appears to have been a gross lack of resources were

01:45:45 been a gross lack of resources were catastrophic the lfb2 had faced budget cuts and the consequential reduction of resources between 2009 and 2016.

01:45:57 between 2009 and 2016. the inquiry must look at these issues in the round these are significant matters which had a causal effect on public officers not being able to properly fulfill their duties in relation to the

01:46:08 fulfill their duties in relation to the preservation of Public Safety proper regulation is needed it must be secured and not left as an option the absence of rigor Independence and

01:46:20 the absence of rigor Independence and transparity from testing regulators and certifiers perhaps of all the evidence the evidence in module 2 in relation to testing was the most shocking

01:46:32 the most shocking it must have been deeply traumatizing for the bereaved survivors and residents the lack of rigor and transparency in testing allowed the manufacturers to

01:46:43 testing allowed the manufacturers to keep the evidence in relation to combustibility confidential even when they themselves were aware of the danger it posed an ethical industry would have put

01:46:54 an ethical industry would have put safety first but they did not profit took precedence and obtaining the market share was pivotal notwithstanding what the industry already knew that this product should not be used to clad

01:47:06 product should not be used to clad high-rise buildings there was an obvious issue the bre were being paid large amounts of money to test products from other private companies

01:47:16 companies they were they were a significant source of Revenue there was evidence that the relationship was not as intrusive as the public might expect from an independent testing regime

01:47:27 regime bre erroneously trusted the honesty of their clients the privatization and poor governance procedures led to companies being able to manipulate testing by setting up test

01:47:38 to manipulate testing by setting up test Rigs and adding items without the bre staff knowing the complete absence of any transparency of test results allowed iconic to hide its products Tech failed tests

01:47:52 its products Tech failed tests the evidence showed that the system of testing was capable of being and was rigged resulting in certificates that were worthless those certificates were relied upon by organizations like the local Authority

01:48:04 organizations like the local Authority building control and the National Health Building Council even when they were suspicious of the results the BBA relied heavily on information from the very companies who wanted

01:48:15 from the very companies who wanted certification for their products there was a lack of intrusiveness by the testing authorities and a misplaced trust that companies who were only interested in profit would voluntary

01:48:26 interested in profit would voluntary inform certifiers of failed test results or inaccurate informational certificates the public deserve to know that products being used on their homes have been

01:48:37 being used on their homes have been effectively and robustly tested and certified safe objectivity and high standards are Paramount

01:48:48 and lastly I want to deal with the lack of accountability to any Observer this has indeed been a merry-go-round of buck passing

01:48:59 merry-go-round of buck passing the commercial bodies have taken no responsibility and shown little if any Contrition for their role in the loss of 72 lives

01:49:08 72 lives not one single organization or commercial body seems to be able to take responsibility for its own emissions in the context of the catastrophe as a

01:49:19 the context of the catastrophe as a whole

01:49:20 whole preferring to move the blame up or down the line but in any event away from their door the only reasonable conclusion that can be reached by this inquiry is that this

01:49:31 be reached by this inquiry is that this is an industry that will not change its culture voluntarily you will recall Paul Hyatt giving evidence before you when he said our

01:49:42 evidence before you when he said our entire industry and all the professions within it and my own included I think there has to be a lot of very careful contemplation from here on

01:49:53 careful contemplation from here on unfortunately from what the inquiry has heard in the course of evidence since he gave that evidence on day 65 this industry as represented in this inquiry

01:50:04 industry as represented in this inquiry has not shown itself capable of such reflection as the mayor highlighted in his closing to modules one and two the architect relied upon the safety engineer the

01:50:16 relied upon the safety engineer the safety Engineers relied upon the claddinger contractor the cladding contractor relied upon the manufacturer who had a commercial interest in remaining silent and they all relied upon the final

01:50:28 and they all relied upon the final Arbiter of building control for compliance without taking any responsibility for it themselves and without providing the information that was necessary for any accurate

01:50:39 was necessary for any accurate assessment to be made no one asked intrusive questions no one offered information that they knew might be relevant to the safety of those living in the tower

01:50:50 living in the tower as Dr Lane said to you fire safety engineering is about protecting people when you forget that you get caught up in the game of making things work and

01:51:02 in the game of making things work and getting things through and you forget about your primary responsibility which is protecting people and the refurbishment of the tower it is hard to see that any organization

01:51:14 hard to see that any organization focused on protecting people at any stage

01:51:19 stage as the inquiry will be aware within that appalling shifting of blame the cladding manufacturer blamed the insulation for the fire spread while the insulation

01:51:31 the fire spread while the insulation manufacturer blame the cladding both distance themselves and the decision made to use their product on Grenville Tower but were content to Market and sell their combustible

01:51:42 Market and sell their combustible products widely and without caveat

01:51:47 the lack of accountability responsibility Candor and transparency from these organizations is shameful the inquiry has one opportunity left

01:51:59 the inquiry has one opportunity left through its phase two report to make findings that give the bereaved survivors and residents the accountability they deserve and are entitled to

01:52:10 entitled to albeit at this very late stage after the fire

01:52:14 fire and recommendations to prevent anything like it from ever happening again no one else must endure what they have had to endure for so long

01:52:27 thank you thank you very much for stud y well that completes the statement that we were expecting to hear this afternoon but we shall be resuming

01:52:39 this afternoon but we shall be resuming tomorrow morning at 10 o'clock when we shall hear further closing statements from call participants followed by a closing statement from Council to the inquiry as I said we'll do that at 10

01:52:51 inquiry as I said we'll do that at 10 o'clock tomorrow and we look forward to seeing you then thank you very much