Opening statements on smoke control system failures. Adrian Williamson QC (BSR) describes TMO's long neglect of SVS since 2010 fire. Stephanie Barwise QC details PSB design flaws - system depressurized lobbies drawing smoke in rather than protecting them. PSB's Lee Bennett responds defending their 'reasonable design response'.
00:00:33 good morning everyone welcome to today's hearing today we're going to embark on a new subject we're going to hear opening statements in relation to the
00:00:44 opening statements in relation to the issue of smoke control systems and i'm going to begin by
00:00:50 by inviting mr adrian williamson queen's council
00:00:54 council to address the panel on behalf of those of the bereaved survivors and residents
00:01:01 residents whom he represents so mr williamson are you there
00:01:06 you there yes indeed mr chairman good morning good good to see you now i i take it you can see me and hear me well indeed i can and we can see you so would you like to make your opening
00:01:17 would you like to make your opening statement thank you very much mr chairman members of the panel good morning uh the uh smoke ventilation system the sbs is yet another story of incompetence and
00:01:29 is yet another story of incompetence and indifference on the part of the tmo and their advisors the svs has a long and checkered history dating from its initial construction
00:01:40 initial construction of neglect and non-compliance and this story is
00:01:44 story is bookended by a serious fire in 2010 and the catastrophic fire of 2017 as the observer rightly commented last sunday the 27th of june
00:01:56 sunday the 27th of june in respect of the 2010 fire quotes the smoke extraction system failed causing inhalation injuries to a number of residents when the grenfell town leaseholders association called for an independent
00:02:08 association called for an independent investigation kctmo fobbed it off by blaming firemen for not knowing how the manual events worked
00:02:15 worked when its own internal maintenance report showed the problem they would events themselves when robert black
00:02:22 black after all this was asked at the inquiry if he took responsibility for the failures on his watch he wriggled and squirmed before distastefully saying pass disdainfully saying past
00:02:35 pass disdainfully saying past the april 2010 fire as you have heard was in flat 64 of the tower and made its way up to flat 156 resulting in mrs saeeda ahmed inhaling smoke shahid ahmed who was
00:02:48 inhaling smoke shahid ahmed who was outside the building at the time rightly described it as a terrifying experience rbkc solicitors subsequently wrote to mrs ahmed solicitors stating that they
00:02:59 mrs ahmed solicitors stating that they were quotes prepared to concede that on the date of the fire
00:03:03 the fire the fire detection system which was in place at grenfell tower was defective and they are accordingly prepared to accept responsibility for your client's claim
00:03:13 claim a few days later janice ray health and safety adviser at the tmo admission to the lfb as follows and could we have please exo 40953
00:03:34 and you'll see that at paragraph three that mess ray refers to a saga in effect whereby remedial work had been required
00:03:47 remedial work had been required it had not been progressed it had not been carried out on time and it had not been carried out prior to the april 2010 fire
00:03:58 prior to the april 2010 fire and as she said in that email as discussed in retrospect the delay should have caused us to consider what if any injury measures were required until repairs were
00:04:09 were required until repairs were completed
00:04:09 completed and the system was fully operational again so
00:04:14 again so that we can get rid of that document please now none of that information had been passed to mr stokes the fire risk assessor it was a typical
00:04:25 the fire risk assessor it was a typical example
00:04:25 example of the tmos laxness and mismanagement mr ahmed subsequently obtained the lfb report of attendance which states that the aov system did not
00:04:37 which states that the aov system did not contain the fire due to a fault in the system the tma continued to state that the smoke spread was as a result of a temporary and minor
00:04:48 was as a result of a temporary and minor fault
00:04:49 fault it is however now clear from dr lane's report
00:04:52 report and tmos all evidence that this was not the case
00:04:56 the case just despite repeated emails from mr ahmed
00:04:59 ahmed to rbkc and the tmo raising concerns about the system including an admission from peter madison in an internal email that the system was quotes beyond
00:05:11 that the system was quotes beyond economic repair close quotes the system was not replaced until more than five years after the 2010
00:05:19 2010 file indeed throughout that five-year period from 2010 to 2015 the tmo were dismissive of concerns
00:05:30 the tmo were dismissive of concerns expressed by residents and others as to the svs
00:05:35 the svs as mr black told the inquiry last week on day 150 it was just quite the same old thing close quotes these failures continued during the
00:05:47 these failures continued during the refurbishment at the design commissioning training and maintenance stages turning them to the early stages of the
00:05:59 turning them to the early stages of the refurbishment in september 2013 prior to design work starting
00:06:06 starting max fordham sought out test certificates for the existing system from the tma they immediately ran into difficulties this process continued for some time
00:06:18 this process continued for some time claire williams confirmed there was a problem obtaining information on the system
00:06:23 system from the maintenance contractor rge it seems that the tmo did not hold this material
00:06:31 material the company psb were contacted as late as november 2013 i.e after the concept stage and even then
00:06:41 then only when it was belatedly identified that an engineering solution would be required
00:06:49 required in the autumn of 2013 mr sims of the architects center building control a description of the proposed upgrade to the smoke
00:07:00 of the proposed upgrade to the smoke system exhaust he rightly observed that quotes
00:07:04 quotes agreement on the smoke ventilation to the tower is the single bigger biggest risk to the proposals but we don't think it is reasonable to leave the existing system in place
00:07:16 the existing system in place in january of 2014 max fordham's matt cross smith chased the maintenance contractor for the svs maintenance records they quote explained
00:07:27 maintenance records they quote explained that as they did not believe that the system worked they could not test it and therefore it had not been maintained for a considerable period of time the
00:07:38 for a considerable period of time the report mr cross smith obtained from rge contained basic errors he received no answers to his questions rge had paid little attention to the
00:07:50 rge had paid little attention to the upkeep of this system which was critical for safety and which was in a state of neglect following the combined inattention of the tmo
00:08:01 the tmo and their maintenance contractors it is apparent that the situation remained
00:08:07 remained unsatisfactory throughout 2014 and the team working on the refurbishment was struggling to get on top
00:08:15 top of the aob issues at a meeting with the lfb the fire brigade in march 2014 it was reported if we could go to max four
00:08:25 four zeros four three five three at page seven please
00:08:41 if we could just highlight the top of the page please where it says visit to
00:08:52 lobby uh so we we see there that um there's a reference to a visit to the lobby on floor five um that the existing system was
00:09:06 five um that the existing system was what
00:09:06 what what situation was not working vents open and closed and a note that matthew ramsey of lfb was very unhappy with the fact that the dampers did not appear
00:09:18 dampers did not appear to be functional there was a risk of a four-week enforcement notice that this was urgent and it was suggested that rbkc's archives were worth trying for details
00:09:30 archives were worth trying for details of the existing smoke length system and that document well as illustrates the lack of information which the tma had and also the lack of maintenance of the
00:09:42 and also the lack of maintenance of the existing system so if we could put away that document now and go to lfb uh four zeros zero zero six eight at page three
00:10:00 and this was an enforcement notice what was served by the lfb uh following up that the meeting i've just referred to and we see there that they note uh under
00:10:12 and we see there that they note uh under article 11 that there was a significant number approximately 25 percent of automatically opening vents within the common parts
00:10:23 the common parts which were not working and that no suitable system of monitoring was in evidence
00:10:28 evidence to identify deficiencies with the svs so um thank you very much indeed so we can get we can dispense that
00:10:40 so we can get we can dispense that document
00:10:41 document moreover even at this late stage in 2014 the system's design philosophy had not been decided the design at that stage was fundamentally different
00:10:52 fundamentally different to the original design offered by fordham's based on pressure deferentials rather than a simple smoke clearance system there are a number of different
00:11:03 there are a number of different recognized mechanical smoke control system design options that could have been adopted by psb
00:11:09 psb and which would have been compliant with both the sca guidelines and adb these options were not considered by psp however there does not appear to
00:11:20 psp however there does not appear to have been any formal consideration of the suitability or advantages or disadvantages of any of the recognized design bases which dr lane sets out in her reports
00:11:31 which dr lane sets out in her reports the enquiries experts have indeed been unsparing in their criticisms of the work done on the svs for example dr lane rejects the
00:11:42 for example dr lane rejects the suggestion that the grenfell system could be regarded as a cult system the differences between the grenfell system and a cult system are numerous and substantial as she
00:11:54 are numerous and substantial as she identifies dr lane in her svs report ultimately concluded
00:12:00 concluded that the system was designed to provide an average open door for velocity and the design did not meet the performance design criteria in the british standard ms
00:12:11 criteria in the british standard ms menzies of this is of a similar view that the design proposal did not fully comply with the standard mainly that only one of the performance criteria of the standard was incorporated into the design
00:12:23 was incorporated into the design proposal
00:12:26 proposal psb's design proposal was performance based
00:12:30 based and only adopted the appropriate air flow criteria across the stair door from the standard it did not adopt the recommended pressure differential criteria in the various spaces
00:12:41 various spaces as mandated by the standard nor the recommended fan temperature which was appropriate for extracting smoke and hot gases from the fire zone as ms menzies points out the dampers
00:12:54 as ms menzies points out the dampers serving the lobby smoke control at every level were required to be smoke control dampers by reference to the sca guide and the british standard in grenfell town the minimum required
00:13:06 in grenfell town the minimum required fire
00:13:07 fire fire resistance to fire resistance duration was e60 s to comply with the adb psb did not specify smoke control dampers and instead
00:13:18 and instead instead specified a product rather than a fire performance this was the gilbert series 54 damper dr lane has analyzed the relevant
00:13:29 dr lane has analyzed the relevant product literature and concluded that they have never been these dampers have never been fully tested
00:13:36 tested to the relevant standard for fire dampers
00:13:39 dampers nor formally classified as such a fire damper
00:13:43 damper is in any event the lowest possible damper standard required to in the adb and is expressly cited as inappropriate for use on protected escape routes dr lane
00:13:54 on protected escape routes dr lane concludes
00:13:55 concludes that the dampers installed across the system were non-compliant with british standards
00:14:01 standards the faults in the design of the system also extended to the control software and instrumentation wiring there were numerous failings in this respect all of which were capable of
00:14:12 respect all of which were capable of causing compartmentation breaches turning then to commission [Music]
00:14:21 mr williams i'm sorry we've lost the sound for the moment um you haven't done anything your end to do
00:14:30 do cause that have you
00:14:33 how's that sir yes now we can hear you again thank you could you go sorry i'm sorry about that that must have been a technical hitch we lost it i was just about to talk about commissioning yes yes turning then to commissioning uh ms
00:14:45 yes turning then to commissioning uh ms menzies is also highly critical of the approach taken by building control to the commissioning of the system
00:14:51 system pointing out that neither mr hanson nor mr hoban
00:14:54 mr hoban accepted the commissioning certificate for the renovated svs neither she says was there any indication that further in commissioning of the amended smoke control system was
00:15:05 amended smoke control system was undertaken building control took a characteristically hands-off attitude as ms menzies puts it there was on their part
00:15:14 part quotes a failure not to require further commissioning and not to have witnessed a further demonstration ultimately ms menzie's view is that a completion certificate for the refurbishment works
00:15:26 refurbishment works should not have been issued by building control
00:15:29 control dr lane is also highly critical of the commissioning work undertaken psb adopted a short form approach to commissioning and failed to adopt the comprehensive 15
00:15:40 and failed to adopt the comprehensive 15 tests
00:15:40 tests recommended by the sca guide of 2015. instead they were satisfied with three performance criteria only this is all the more concerning when one considers that mr mahoney
00:15:52 when one considers that mr mahoney of psb had not analyzed the performance of the original descript system as described in cp3 of 1971. furthermore the original system did not
00:16:03 furthermore the original system did not have any performance records that the designer could use to ensure that the renovation was performing to at least the same standard as required by the building regulations
00:16:15 as required by the building regulations only three performance parameters were chosen and these parameters were not sufficiently tested dr lane also quotes found no evidence of any designer specifying fire resistance
00:16:26 any designer specifying fire resistance or smoke leakage performance for the lobby dampers this raised obvious safety concerns about the ability of the system to maintain
00:16:37 maintain compartmentation and restrain smoke movement from one part of the tower to another
00:16:43 another the psb commissioning documents and technical submissions make no reference to the overall commissioning scope neither throughout the document is there any reference of the need to assess
00:16:55 any reference of the need to assess the performance of the system over a range of reasonably foreseeable scenarios
00:17:00 scenarios that should have formed the basis of the design
00:17:03 design these fundamental emissions are symptomatic of wide-ranging systemic design and commissioning failures
00:17:11 failures there is also no evidence that appropriate training was provided to representatives either of the tma for maintenance purposes
00:17:19 purposes or the lfb as to how to use the system in the event of a fire this is despite the fact that the standards maintain that the responsible person ensures that
00:17:30 that the responsible person ensures that the appropriate training is given before accepting the system maintenance of the new system was equally inadequate just a week before the fire on 6th june
00:17:43 just a week before the fire on 6th june 2017
00:17:45 2017 s wright notified psc that they had received a defect notice from writing that the aovs were not opening up and requested an appointment to be arranged to attend to resolve mata
00:17:58 arranged to attend to resolve mata jsw clearly regarded this as urgence urgent since they sent follow-up emails over the next two days richard thornley on behalf of whitton's son emailed jsw
00:18:10 son emailed jsw on 8th june 2017 as follows and if we could go to psb40479 please
00:18:28 and if we could go to psb40479 please uh you see at the at the bottom of that email mr thornley writing regarding the fault at grenfell tower after checking with psb the site is um out of warranty and has not been
00:18:39 out of warranty and has not been serviced a quote was attached and then they noted significantly the site under fire regulation should be serviced every six months
00:18:50 months with its being life safety equipment and then if you scroll up to the top of that email please
00:18:58 we we see that um jsw responded on the 12th of june just a couple of days before the fire and asking for
00:19:10 and asking for a quote to be provided thank you if we could that's enough from that email please it seems that an appointment was booked
00:19:22 it seems that an appointment was booked for this work to be done but it was not carried out prior to the fire
00:19:28 fire dr lane found in her phase one report that there was no evidence that the defect was rectified it is likely that all the failures that i have highlighted
00:19:40 i have highlighted and which are set out in detail in the expert evidence contributed to the system not functioning on the night of 14th june 2017.
00:19:51 of 14th june 2017. on that night the abud family in flat 92 on the 12th floor barely managed to escape
00:19:59 escape they only made it through the lift lobby area and down the stairs with the determined assistance of lfb control room officer peter duddy who guided them all the way
00:20:10 peter duddy who guided them all the way down
00:20:12 down poignantly he told them just before 3 am quotes you've got to go be brave and try to get through that smoke
00:20:24 smoke good luck just run so that that concludes the oral submissions on behalf of team two and we're very grateful for the opportunity we have been afforded
00:20:36 opportunity we have been afforded to make those submissions thank you very much well thank you very much indeed mr williamson i'm now going to invite um stephanie barwise queen's council to make an opening statement on behalf
00:20:49 to make an opening statement on behalf of those of the the reef survivors and residents whom she represents so uh miss barwise are you there i am indeed sir oh good morning
00:21:02 there i am indeed sir oh good morning good morning good to see you we can see and hear you clearly i hope you can see and hear me clearly yes indeed sir good well thank you very much well then would you like to make an opening statement on behalf of your clients
00:21:15 statement on behalf of your clients certainly and good morning to mr sister fan and to mr eric for also you have our written submissions which i don't propose to repeat but rather to focus on three broad points
00:21:27 focus on three broad points first psv's approach to this inquiry including its recent change in position on the nature of the design of the smoke control system second principle design flaws and
00:21:38 second principle design flaws and finally
00:21:39 finally psv's defense of its system as set out in its opening starting with psb's approach to the inquiry
00:21:48 inquiry psb submissions begin by acknowledging that yet
00:21:51 that yet further submissions from yet more corporate core participants who do not accept responsibility for failings are unwelcome we agree psb goes on to warn the inquiry that
00:22:04 psb goes on to warn the inquiry that fairness demands that it have a reasonable opportunity to challenge dr lane's evidence we agree again but submit that psb has not availed itself of the opportunity to
00:22:15 not availed itself of the opportunity to challenge dr lane which it has thus far been afforded psb was alerted by appendix j of dr lane's phase 1 report back in april 2018 to some of the
00:22:27 back in april 2018 to some of the principal flaws in the design of its system and to the fact that it had not functioned as intended since dampers other than those on the fire floor had remained open
00:22:39 on the fire floor had remained open during the fire importantly dr lane alerted psb to two specific points first the system is designed was not a pressure differential system as defined
00:22:51 pressure differential system as defined by adb-2
00:22:53 by adb-2 and bsen12101 part 6 and was therefore a bespoke system second that as the performance criteria of the system were not defined she was unable to
00:23:06 were not defined she was unable to confirm that the system complied with the functional requirements of the building regulations that was throwing down a gauntlet to psb to justify its system psb however
00:23:19 to justify its system psb however failed to pick up the gauntlet in that even now
00:23:23 even now after two witness statements from its principal designer mr mahoney the explanation for his chosen design including the assumed designed conditions and performance standard he
00:23:34 conditions and performance standard he hoped to achieve are nowhere set out psb has therefore had since april 2018 to explain the basis of its design and yet has failed to do so
00:23:47 yet has failed to do so the suggestions now made in psb's module 3 smoke control opening submissions are no more than creative afterthought which is not as yet at least supported
00:23:58 which is not as yet at least supported by an expert despite the suggestion psb may seek to apply for one it is unclear why psb a member of the whit
00:24:07 whit uk group if genuinely seeking to participate in the inquiry would not have taken expert advice on its system between april 2018 and now
00:24:19 between april 2018 and now given the serious flaws lane identified in it
00:24:22 in it in her april 2018 report it is not clear whether or not psb has already consulted an independent expert but
00:24:32 but if it has it has not to date ask for its expert opinion to be given to the inquiry
00:24:37 inquiry to counter dr lane's initial key findings
00:24:41 findings from which she has not resiled psb has changed its position as to the design of the system and yet the reason for that change is not explained in psv's module 3 opening
00:24:54 not explained in psv's module 3 opening submissions the design of the smoke control system at grenfell should have been a bespoke system designed in accordance with certain principles but as i will explain it does not comply
00:25:06 but as i will explain it does not comply with those principles and until very recently psb had led us all to believe that their system was a system
00:25:13 system designed primarily in accordance with the british standard expressly referred to in adb volume 2. the change in position arose in the
00:25:24 the change in position arose in the following way as the system is a mechanical as opposed to natural extract system it could theoretically have been designed as a preferred pressure differential system
00:25:36 differential system under paragraph 2.27 adb2 which in turn refers to the prescriptive requirements of bs en 12101 part 6 which concerns pressure differential
00:25:48 which concerns pressure differential systems
00:25:50 systems systems under bsen 101 part 6 can be either pressurization or depressurization systems if a depressurization system is chosen
00:26:03 if a depressurization system is chosen it must not depressurize the areas to be protected namely both the stairs and the lobbies therein lies the problem psv's system
00:26:15 therein lies the problem psv's system did depressurize a part of the areas which should have been protected namely the lobbies if psp's system were designed to be a depressurization system of the type
00:26:26 depressurization system of the type defined by bsen 12101 part 6 it would be a demonstrably non-compliant system furthermore given the physical constraints in grenfell
00:26:38 constraints in grenfell extended distances from flats and fixed shafts
00:26:43 shafts bsen102101 part 6 should anyway not have been followed and a bespoke system should have been chosen such systems should have been designed in accordance with the smoke control
00:26:55 in accordance with the smoke control association guide or sca guide psv now claims by mr mahoney's second statement and its module 3 smoke control opening submissions that its system was indeed a
00:27:07 submissions that its system was indeed a bespoke system and was not designed to comply with bs 12101 part six albeit two performance criteria were selected
00:27:17 selected from that standard importantly however mr mahoney does not claim that the system was designed in accordance with the sca guide and dr lane says it was not furthermore
00:27:30 and dr lane says it was not furthermore psb's technical submission at the time of the contract had referred only to the design being in accordance with bs one two one on one part soviet suggesting it might not conform in full
00:27:41 suggesting it might not conform in full with that standard had been removed at the removed at the request of mr hansen of rbkc building control apparently because his then understanding was that
00:27:53 because his then understanding was that it had been designed on the basis of bs-12101 part 6. psb had consistently maintained from its phase one opening in april 2018
00:28:04 from its phase one opening in april 2018 until mr mahoney's second statement dated the 26th of march 2021 that the system was designed primarily in accordance with the principles of bs 1 to 101 part 6.
00:28:17 1 to 101 part 6. mr mahoney's second statement introduced the suggestion that the system was a performance-based system which was similar
00:28:24 similar to a proprietary system known as the cultural system dr lane concludes the system should have been designed as a performance-based system
00:28:34 system in accordance with the requirements of the sca guide but is not a cold chart system importantly mr mahoney does not claim that his system was designed in accordance with the sca guide
00:28:48 in accordance with the sca guide it should be noted that mr hansen now asserts
00:28:51 asserts in his first witness statement that the system was designed in accordance with the sa
00:28:56 the sa sca guide and indeed mr hansen had originally asked that it be so designed if it could not be shown to be no worse than the existing system this aspect of the evidence will clearly
00:29:08 this aspect of the evidence will clearly need to be explored carefully turning to the key flaws in the system the system is designed by psv does not comply with the functional requirements of building regulations b1 b3
00:29:21 of building regulations b1 b3 and b5 because it did not keep the stairs
00:29:24 stairs relatively free of smoke but also failed to promote tenable conditions for travels through the ventilated corridors which are grenfell other lobbies
00:29:35 grenfell other lobbies there are various flaws in the design which may explain this first psp's system depressurized the lobbies
00:29:43 lobbies thereby drawing smoke into them and as a result
00:29:47 result only the stairs rather than the lobby and the stairs were protected areas secondly psp's system was flawed because it overlooked the scenarios during a fire at grenfell
00:30:00 the scenarios during a fire at grenfell which it should have assumed in its design namely that a minimum of three doors
00:30:05 doors would be open at once fire flap door door between the lobby and stairs and the lobby and stair door on the floor below because the firefighters would use the dry riser
00:30:17 firefighters would use the dry riser on that floor below the fire floor for safety psp's design however assumed that only a single door would be open
00:30:28 open thirdly as millennia foreign williamson has said
00:30:32 has said the dampers namely mechanical closures used to close the ducts did not conform to the requirements for a smoke control system nor for a protected shaft which the
00:30:43 nor for a protected shaft which the shafts at grenfell were the dampers used were the lowest possible standard namely fire dampers when they should have been smoke control dampers
00:30:54 have been smoke control dampers this incorrect specification flowed from the fact that psb had failed to appreciate that the shafts at grenfell were protected shafts in order to maintain compartmentation in
00:31:06 in order to maintain compartmentation in accordance with functional requirement b3 of the regulations that failure to appreciate that the shafts at grenfell were protected albeit a fundamental error was clearly
00:31:18 albeit a fundamental error was clearly an error
00:31:19 an error also made by other members of the design team
00:31:22 team max fordham had received psv's original technical submissions and approved them subject to building control approval subsequently max fordham made comments on the psv's
00:31:34 max fordham made comments on the psv's technical submission in february 2016 and yet
00:31:37 and yet again failed to point out that the shafts were protected shafts and that smoke control dampers not fire dumpers were required the failure of the dumpers is highly
00:31:48 the failure of the dumpers is highly material
00:31:50 material on the night the extract fans at level two in the south shaft and at the top of the north shaft do not appear to have functioned correctly with the result that smoke was trapped both in the north
00:32:03 that smoke was trapped both in the north and
00:32:03 and south shafts and as well as leaking out of open dampers smoke may according to dr lane also have leaked through closed dampers
00:32:27 and available of the system but without having any contemporaneous evidence of matters said to have been considered in the design and in some respects unsupported by mr
00:32:38 and in some respects unsupported by mr mahoney's evidence further absent expert opinion to support the submissions the points made are nothing more than lawyer's submissions as to the basis of the design psb makes
00:32:51 as to the basis of the design psb makes six principal points first psb submits it is
00:32:56 it is its design accorded with the sca guide and was
00:32:59 and was a reasonable solution psb's position is somewhat contradictory in that on the one hand it submits at paragraph 46 that in mr mahoney's judgment it was not
00:33:11 that in mr mahoney's judgment it was not reasonably practical to design a system for the building which precisely conformed to any standard or guidance and yet in the following paragraph psb submits
00:33:21 submits that it considers that mr mahoney's design did conform to the sca guide second psv asserts the system was not a prefer pressure differential system within the
00:33:33 pressure differential system within the meaning of bs 12101 part 6 or as referred to in the sca guide
00:33:39 sca guide rather it was a mechanical system this relies on mr mahoney's new and precarious position that although he described it as a depressurization system
00:33:51 depressurization system it is not a pressure differential system even though all available guidance describes a depressurization system as one of two pressure differential
00:34:02 as one of two pressure differential systems
00:34:03 systems psp's submissions failed to address mr mahoney's
00:34:07 mahoney's unexplained change of position on this point
00:34:11 point third psv claims the decision to focus on protecting the stairs not the lobbies was reasonable in reliance on the sca guide and the lga guide as to the sca
00:34:24 and the lga guide as to the sca guide psv relies on paragraph 5.2.1 the guide merely states that it is considered more important to protect the stairs and the corridors as the stairs will be used by more
00:34:36 as the stairs will be used by more people
00:34:37 people however that is very far from a suggestion that it is acceptable for the lobbies to positively suck in smoke thereby preventing residents from leaving their flats
00:34:49 from leaving their flats in order to escape as the inquiry is acutely aware and the new members of the panel will wish to be aware many residents on the night opened their doors and immediately shut them
00:35:01 doors and immediately shut them due to thick smoke which prevented their escape
00:35:05 escape this was particularly true of the number four flats which have the longest travel distances
00:35:11 distances almost damasi and ethiopia are safer in flat 94 and are an example of those who were repeatedly forced by thick smoke to abandon attempts to escape but were
00:35:23 to abandon attempts to escape but were mercifully rescued by firefighters just as flames burst into their flat others such as franuslav lucic in flat 84
00:35:32 84 and ed stefan in 134 became confused in the smoke on the lobbies
00:35:39 lobbies as to psv's reliance on the lga guide that guide's intended readership is as is clear from paragraph 4.2 of the guide designed for various housing providers
00:35:51 designed for various housing providers enforcers
00:35:52 enforcers and fire risk assessors often dealing with
00:35:55 with old systems which have not been recently refurbished and as such cannot be said to equate to good practice for designers of smoke control systems in any event
00:36:08 of smoke control systems in any event and importantly mr mahoney does not even in his second witness statement claim to have referred to
00:36:15 to or relied upon the lga guide fourthly there is apparently a dispute as to whether the escaped distances from certain of the flats were extended to a distance which required to
00:36:26 extended to a distance which required to be compensated for by enhanced ventilation namely over 10 metres
00:36:32 metres dr lane in her ventilation report has measured the longest distance at 10.5 metres but this may possibly be a hangover from her original phase 1
00:36:43 a hangover from her original phase 1 report
00:36:43 report which was corrected by her phase 1 correction report to 10.3 meters for the transcript the diagram showing how dr lane calculates the 10.3 meters
00:36:56 calculates the 10.3 meters in her correction report is figure 15.5 at vlas 5037 page 25. psb refers to the bre report
00:37:09 page 25. psb refers to the bre report produced for the metropolitan police not the inquiry which records the distance from the number four flats as 9.3 meters however unlike dr lane's report there is
00:37:20 however unlike dr lane's report there is no supporting diagram to show how the measurement was made in any event if psb had wished to take issue with dr lane's travel distances
00:37:31 issue with dr lane's travel distances they could have done so after the issue of her first report in april 2018 when the 10.5 meters was recorded
00:37:39 recorded or at latest after the issue of her corrections report in mid-november 2018 which gave the lower measurement of 9.3 meters
00:37:48 meters in other words this point could and should
00:37:51 should have been raised by psb some two and a half years ago that the point is raised now by submissions indicates a desire to defend rather than
00:38:02 indicates a desire to defend rather than to cooperate fifth psv claims that the two principal performance criteria selected for its system
00:38:10 system were a minimum air velocity of two meters per second across the open door to the stair to protect the stair when that door was open and a maximum door opening force of 100
00:38:21 and a maximum door opening force of 100 newtons
00:38:22 newtons achieved by limiting the pressure differential between the lobby and stairs
00:38:26 stairs to minus 25 pascals both the 2 meters per second velocity and requirement for a maximum door opening force of a hundred newtons derived from bs12101 part six
00:38:40 derived from bs12101 part six as mr mahoney had asserted in his first statement
00:38:44 statement however psv is now at pains to find other possible derivations for these two principal
00:38:51 principal performance criteria noticing noting that the two meters per second velocity and the minus 25 pascal requirement are the same as those in the labc registered culture system
00:39:05 in the labc registered culture system this is irrelevant as mahoney accepts that the system at grenfell was not a cultural system further psv relies on bre's report entitled smoke
00:39:16 on bre's report entitled smoke ventilation of common access areas of flats
00:39:19 flats which notes that the non-fire performance for depressurizing the corridor could subject to considering fire events be defined as those in bs
00:39:30 fire events be defined as those in bs five triple eight part four which gave a velocity
00:39:33 velocity of two meters per second at the open door but as psb notes that was simply the precursor two one one two one one part six and
00:39:44 two one one two one one part six and therefore this does not assist psv in establishing a wider basis for the acceptability of two meters per second
00:39:52 second and also by definition relates to a pressure differential system which psb now claims its system is not furthermore the argument overlooks dr
00:40:03 furthermore the argument overlooks dr lane's fundamental point that the sca guide requires that in order to determine what the performance criteria
00:40:11 criteria should be the designer must consider the design conditions namely open and closed doors under which those criteria must be met sixth psv relies on mahoney having built
00:40:25 sixth psv relies on mahoney having built some robustness into the system by adding
00:40:28 adding fifty percent to the volumetric flow rate an
00:40:31 rate an uplift which as psv acknowledges also derives from vs12101 part six psv asserts a further margin of comfort was added by the fans being specified to
00:40:44 was added by the fans being specified to produce a higher extract rate than required and the rate was 5.6 meters cubed per second
00:40:52 second psb asserts at paragraph 80 of its opening
00:40:56 opening that mahoney considered at the time that this slack built into the system meant
00:41:03 meant that even if an extra door were open the system could still cope first of all mr honey nowhere suggests that he considered this scenario
00:41:14 scenario the second in any event even had he done so
00:41:17 so the system still failed to address the design condition which he should have assumed at grenfell namely that three
00:41:25 three not two doors were open as a concluding remark we note that psv relies on the approval of building control
00:41:33 control and of max fordham as somehow justifying its design the fact that other professionals may also have been at fault in failing to appreciate obvious deficiencies in the system is of
00:41:46 obvious deficiencies in the system is of course no defense to psb um unless i can assist further so those are my submissions and thank you thank you very much indeed
00:41:57 and thank you thank you very much indeed that's very helpful now next i'm going to invite
00:42:01 to invite mr lee bennett to make an opening statement on behalf of psb so mr bennett are you there
00:42:18 miss chen good morning are you able to hear me good morning mr bennett yes we can see and hear you can you see and hear me
00:42:26 hear me i can indeed so i will count that as a reasonable start very good thank you very much when i um this is your opportunity to make a statement on behalf of your client so off you go uh mr chairman
00:42:40 off you go uh mr chairman mrs fund mr ackball thank you for the opportunity to address you this morning mr chairman as you've kindly indicated i represent
00:42:49 represent psb and what i have to say by way of opening statement is submitted on its behalf
00:42:57 behalf um i'm grateful to mullen friend um stephanie barwise queen's council for setting out much of what he set out in our written opening which i know uh you have um before i do say anything
00:43:10 uh you have um before i do say anything further
00:43:11 further it's right that psp should want to say that all those concerned with the refurbishment project at the company past and present are acutely conscious
00:43:23 past and present are acutely conscious of the lost and the devastated lies because of the fire at the time it is as sparse foreshadowed appreciated that yet
00:43:34 foreshadowed appreciated that yet further submissions from yet more companies which do not accept feelings or admit that they fell short are unwelcome
00:43:43 unwelcome however counterintuitive as it might seem
00:43:47 seem it is we submit important for your work that core participants are afforded a reasonable opportunity to challenge the evidence
00:43:58 evidence provided to the inquiry where they do not agree with it that way there is at least the potential for the work of the inquiry to be robust
00:44:09 for the work of the inquiry to be robust and correct if i can be blunt mr chairman i think we all share
00:44:15 all share the legitimate interest in your work being correct and getting it right and and i hope i will be forgiven therefore for setting out my stall on behalf of my
00:44:27 for setting out my stall on behalf of my client
00:44:28 client because i think i hope we can all nod in agreement that must be the right approach
00:44:33 approach and it's certainly in that in that spirit that i made this opening statement on behalf of psb
00:44:41 mr chairman i do need to say something on the inquiry procedure so that the wider community listening to these proceedings is able to understand the context
00:44:51 context of my submissions expert reports on smoke control have been disclosed to core participants only very recently disclosure was completed on the 9th of
00:45:02 disclosure was completed on the 9th of june 2021
00:45:04 june 2021 the reports of miss menses and dr lane comprise 765 pages of detailed expert evidence um i'm not looking for sympathy but this
00:45:16 um i'm not looking for sympathy but this chronology does place psb and its witnesses from whom the inquiry wishes to hear in a difficult position with exceptionally short time to consider that material evidently from
00:45:30 to consider that material evidently from the
00:45:30 the written and oral submissions the inquiry has received some core participants are wedded entirely
00:45:37 entirely to the assessment provided by dr lane and their submissions are in effect on articulation of the content of dr lane's report now bsb continues to review the detail
00:45:49 now bsb continues to review the detail of those reports but to be clear psb does not accept the assessment made by dr lane and will look to challenge it mr chairman
00:45:59 chairman it is not for me by way of an opening statement
00:46:02 statement to look to present expert opinion evidence
00:46:05 evidence in rebuttal to that advanced by dr lane and i should be careful not to do so we have until the 12th of july 2021 to
00:46:16 we have until the 12th of july 2021 to settle
00:46:17 settle questions both experts we will do so an application for the inquiry to receive additional advice on the topic of smoke control is not discounted at this stage
00:46:29 is not discounted at this stage it follows mr chairman that i will not deal with certain matters today particularly in relation to the events of the night of the farm and dr lane's assessment of that evidence
00:46:41 mr chairman two witnesses are going to be called next week from psb that's mr hugh marnie who is the principal designer of the system and mr granville parkflow the
00:46:53 system and mr granville parkflow the commissioning engineer these witnesses have had very little opportunity to know and understand those aspects of the recently disclosed reports that touch
00:47:04 recently disclosed reports that touch on them and any criticisms leveled against them as the inquiry takes the evidence on this topic and hears from these witnesses
00:47:15 hears from these witnesses the inquiry is therefore respectfully asked to bear that in mind and to ensure please that the questioning process is fair
00:47:27 mr chairman psb anticipates that some aspects of the forthcoming evidence will be challenging for it
00:47:34 for it particularly some of the opinions expressed by dr lane its work has been subject to intense scrutiny over a period of years now
00:47:45 scrutiny over a period of years now and there may well be aspects of its work on the grenfell tower project that could have been done better nevertheless whilst it continues to carefully review
00:47:56 whilst it continues to carefully review dr lane's evidence the headline summary of psp's position is as follows i'm going to do this mr chairman in the hope that it assists you i'm going to set out effectively
00:48:07 set out effectively uh psp's position by reference to seven points
00:48:12 first the system designed by psp for grenfell tower was in all circumstances a reasonable design response
00:48:24 second where the building regulations apply to the system we say that it did comply with the relevant requirements of schedule one
00:48:37 so far as relevant to its um part of the refurbishment works we submit the system provided so far as was reasonable in the context of
00:48:49 far as was reasonable in the context of an existing legacy residential building quote appropriate means of escape end quote which is b1
00:49:00 and secondly reasonable facilities to assist firefighters which is b5
00:49:11 third in the alternative and so far as it relates to the works to the system the building was no more unsatisfactory in relation to the relevant requirements
00:49:22 in relation to the relevant requirements of schedule 1 than it was before the work was carried out
00:49:27 out thereby meeting we say the building regulations fourth in relation to the testing and commissioning of the system whilst
00:49:39 and commissioning of the system whilst acknowledging that the paperwork and record keeping was less than optimum in relation to the testing and commissioning process psb presently considers that the testing and commissioning of the system was
00:49:51 and commissioning of the system was completed satisfactorily mr chairman mr partlow has given a detailed written accounts of what he did to the inquiry you will hear from him next week
00:50:02 next week and obviously mr chairman you and your panel members will form your own assessment of his evidence if i may say so it is correct that the system was witnessed on
00:50:15 correct that the system was witnessed on a number of separate occasions by a number of parties and no concerns were raised at any time during or after any such demonstration
00:50:26 during or after any such demonstration my position therefore is that when psp left site in april 2016 the system was working as intended fifth whether the system operated as
00:50:38 fifth whether the system operated as intended or not on the night of the fire which as you'll notice some 13 and a half months after psb left side is addressed by dr lane in her
00:50:49 lane in her recent report now prior to the receipt of that report psp had considered this matter carefully and psp is confident that a complete and objective view of all the evidence
00:51:02 and objective view of all the evidence and ought to result in the conclusion that the system did operate on the night of the fire at least
00:51:09 least during the period when the circumstances remained
00:51:13 remained within the designed four conditions six the extent to which the system may
00:51:25 six the extent to which the system may or may not have contributed to internal smoke spread within the building by way of any breach of compartmentation or otherwise is also addressed by obsolete in a report again
00:51:36 obsolete in a report again prior to receiving that report psb had considered the evidence and presently sees no basis upon which to reasonably draw any conclusion that the system caused or
00:51:47 any conclusion that the system caused or materially contributed to a breach of complementation within the building when the circumstances remained within the designed four conditions
00:51:59 seventh the extent to which any such breach of compartmentation as may be established in relation to the system
00:52:08 system cause or contributed to the outcome of the file
00:52:12 the file is an issue which should only be approached with the utmost care and sensitivity i have to say mr chairman that in the context of a catastrophic cladding fire
00:52:24 context of a catastrophic cladding fire such as happened at the time even if the alleged failings of the system were to be established with confidence psb
00:52:33 psb presently sees no basis upon which to reasonably draw any conclusion that such failings caused or materially contributed to the outcome of the fire mr chairman
00:52:46 to the outcome of the fire mr chairman those those seven um statements set out psp's position what i'd like to do now is um add a little bit more detail in order to
00:52:57 little bit more detail in order to explain those those positions and i do that by reference to nine points which i shall cover by way of question and answers and i hope that these help you and your fellow panel members
00:53:09 fellow panel members ahead of you hearing evidence on this topic
00:53:13 topic question one where do smoke control systems
00:53:17 systems fit in as an active protection measure it's essential to remember that a smoke control system is but one part of the passive and active
00:53:28 one part of the passive and active protection measures that are required to ensure
00:53:31 ensure adequate fire safety within a building the smoke control provisions include compartment walls external wall system flat entrance doors fire stopping to services
00:53:43 fire stopping to services stairway doors stairway enclosures and a smoke control system now adequate protection is only insured if these measures contribute as required
00:53:55 contribute as required in the helpful words of miss menses quote the circle of mutually supportive measures
00:54:03 measures must be complete end quote
00:54:07 maintaining compartmentation within a tall residential building is the fundamental principle on which adequate fire safety is insured the failure
00:54:19 is insured the failure of some of the above passive measures can have a significantly greater impact than
00:54:25 than others not least because active measures such as a smoke control system
00:54:32 system um depend on those passive measures to deliver the conditions under which smoke is expected to arise so that it can reasonably be managed
00:54:45 so that it can reasonably be managed so mr chairman any assessment of a smoke control system and evidence pertaining to it should only be undertaken in circumstances where evidence relating
00:54:56 in circumstances where evidence relating to the other mutually supported measures is retained firmly in the mind mr chairman if i may that that's a task that i would certainly urge upon you and your fellow panel members
00:55:09 you and your fellow panel members question two what is expected of smoke control systems we covered a lot of this ground in phase one but if i may it's important that i underline it again
00:55:20 underline it again it's equally important we say that when taking evidence to remember the proper and legitimate design bases for these systems
00:55:28 systems these are first fires do not normally start in two different places in a building
00:55:33 building at the same time and there is a low probability that a fire will spread beyond the flat fire origin second the assumed design
00:55:44 fire origin second the assumed design fire is a fire starting in a single location and being contained within a single compartment snow control systems are therefore only
00:55:56 snow control systems are therefore only intended to address the effects of a fire
00:55:59 fire on one floor and to deal with smoke from a single
00:56:03 a single compartment fire no more
00:56:09 consequently the system in the tower was intended to operate on one floor only the system could not have prevented smoking files of multiple floors impacting lobbies and the common stair on multiple levels
00:56:22 and the common stair on multiple levels whilst this is directly acknowledged by those making opening statements it is not adequately reflected in the actual submissions made by some therefore an important function of the
00:56:33 therefore an important function of the panel
00:56:34 panel in hearing the evidence will be to keep the evidence in perspective and to measure it against the universally accepted limitations of such systems
00:56:46 limitations of such systems third question what were the particular constraints in respect of the system works at the tower
00:56:56 as you've already heard psb was engaged late in the construction journey neither exover as fire engineer or max fordham's part of the design team resolved the smoke control requirements
00:57:07 resolved the smoke control requirements before the refurbishment works were tended
00:57:10 tended there was an old and likely inoperative smoke control system um which i know you've heard an awful lot about now so i'm not going to repeat it
00:57:18 it um in respect to which the london fire brigade served a deficiency notice bsr team 2 suggesting their written submissions that by virtue of psp's late
00:57:29 submissions that by virtue of psp's late instruction psb was presented with a fatal complete at which point the smoke control system renovation was reduced to the lowest common denominator of not making the building
00:57:41 denominator of not making the building worse
00:57:43 worse mr chandler there can be little doubt that the timings on this project were pressured
00:57:48 pressured however that is not necessarily unusual in the context of this form of sub sub contracting work nevertheless mr mahoney's intention was
00:57:59 nevertheless mr mahoney's intention was aligned with other members of the design team
00:58:03 team to still improve the existing systems significantly
00:58:10 there are however particular acute constraints presented by the tower which um we say had a considerable impact on the approach that could be taken
00:58:20 taken to the design of the system
00:58:23 mr chairman i hope you forgive me for setting these out but i these are going to be important things to bear in mind as you hear the evidence firstly psb was required to use the existing smoke extract inlet
00:58:35 existing smoke extract inlet shafts on floors 4-23 it was required that those shafts be extended down to the lower levels of the tower
00:58:43 tower such as a complete smoke control system encompassing all floors of the building could be required they were the requirements to which pspc psp had to work
00:58:54 had to work now the dimensions of the existing charts are particularly small 0.96 square meters that's well below the 1.5 square meter benchmark for an adb
00:59:05 adb natural shaft obviously all the existing apertures in the smoke shafts also had to be used and critically the tower was to remain occupied
00:59:15 occupied throughout any works fourth question what were the regulatory requirements in respect of the system at grenfell town and mr channel we've provided a detailed
00:59:27 and mr channel we've provided a detailed written opening and paragraphs 29-36 36 detail lists for you and i've already summarized my position in points two and three of my summary
00:59:40 two and three of my summary for present purposes may underline just three short points actually i'll i'm going to cut it to two for you just to i'm conscious of time um first that the requirements
00:59:52 um first that the requirements under schedule one are functional in their nature so they tell you what the outcome to be achieved is but they don't tell you how to do it
01:00:04 you how to do it so in requiring the provision of appropriate means of escape or reasonable facilities for firefighters they don't tell you or set out what specific standards
01:00:15 specific standards are required second the core of any assessment under the building regulations is the concept of reasonableness
01:00:26 the concept of reasonableness mr chairman if i make one plea it is really here that i rely on you and your fellow panel members to bring
01:00:36 bring a real sense of reasonableness to your assessment under the building regulations of the works that my client psb undertook because that is absolutely
01:00:47 psb undertook because that is absolutely essential
01:00:48 essential to any assessment of compliance under the building regulations
01:00:54 now how psb um looked to meet those functional requirements is my fifth question and again we have set this out in detail in writing
01:01:10 in writing in short however um although it's said that there is a um dispute between the various accounts or uh inconsistency between the various accounts that mr mani has put forward
01:01:23 accounts that mr mani has put forward you will have to cut through that in our respective mission
01:01:30 in this case mr marley brought his experience competence and practical engineering skill to bear on the project his view was that it was not feasible to apply the precise
01:01:43 not feasible to apply the precise terms of one standard or one guidance document
01:01:47 document his performance-based design looked to significantly improve on what was there and so far as it was reasonable and practical to do so to make appropriate provisions for means of
01:01:58 appropriate provisions for means of escape
01:01:59 escape and reasonable facilities for firefighters what does that mean mr chairman is quite straightforward the resultant system was not a pressure differential system
01:02:10 differential system within the meaning of bs en 12 101-6 it was never intended to be and we say it was not stated to be either the system was
01:02:24 stated to be either the system was within the meaning of the sca guide a mechanical powered smoke control system
01:02:31 system mr mani confirmed that his design for the system was a mechanical extract system similar to two but not the same as the quote mechanical extract natural
01:02:44 the quote mechanical extract natural inlet system detailed in the sca guide
01:02:49 mr chairman perhaps those two words are helpful just to look at it's mechanical extract because it's extracting from the lobbies and it's natural inlet because you'll recall that the head of the stair there is a permanently open
01:03:01 the stair there is a permanently open louver
01:03:02 louver which takes fresh air into the stair core and it's that flow from the stair into the lobby which is the essence of the mechanical system
01:03:15 ms menzies recognizes the distinction between
01:03:18 between pressure differential systems and mechanical powered smoke control systems and ms menses your expert concludes that the system was a mechanical extract
01:03:29 that the system was a mechanical extract system
01:03:30 system designed to depressurize the lobby and induce an airflow from the ventilated stair
01:03:35 stair into the lobby but that she did not believe the system was intended to be a pressure differential system designed in accordance with bs en 12
01:03:46 designed in accordance with bs en 12 101-6 respectfully mr chairman we agree with ms menzies and say that she is correct
01:03:54 correct in her analysis this is an important distinction because it is only from the position of correctly
01:04:04 correctly understanding the system that one can fairly and properly assess whether or not the system met the requirements of the building regulations in short the relevance of bs
01:04:17 in short the relevance of bs en 12101-6 to which dr lane and those adopting her critique are so closely wedded falls away
01:04:30 sixth question wasn't the design objective to focus on the protecting stair a reasonable one we say it was and we've given you four references
01:04:42 and we've given you four references to um excellent guidance which support that position firstly in adb secondly in british standard triple nine one thirdly in the sca guide and fourthly in
01:04:55 thirdly in the sca guide and fourthly in the lga guide now before you know mr chan we set those out in paragraph 53 to 64 of our written submissions which i would invite you and the panel members to please
01:05:06 you and the panel members to please considering your own time
01:05:11 my seventh question if the design objective was to focus on protecting the staircase
01:05:17 staircase were the performance criteria selected appropriate and sufficient for means of escape and firefighting phases there are two performance criteria in
01:05:29 there are two performance criteria in the design a minimum air velocity of 2.0 meters per second across the stair door to protect the staircase and secondly a maximum door opening force for closed
01:05:41 a maximum door opening force for closed escape route doors of 100 newtons and that that force was achieved by limiting the pressure differential between the lobby and stair 25 mascaras
01:05:53 mr mahoney's evidence is that the minimum 2.4 metres per second velocity across the door was taken from bsen 12101-6
01:06:05 was taken from bsen 12101-6 as the velocity required across an open stair door for a class b presidential difference system mr mahani considered this to be appropriate not
01:06:18 considered this to be appropriate not because his design was a class b pressure differential system but because the outcome in that system of that
01:06:29 in that system of that velocity was the same in his system as it was in that system
01:06:36 mr mahoney also says that he knew from experience that 2.0 velocity through an open door is the airflow that's required to enable smoke to be kept out of the stair
01:06:50 my friend miss barwise has um far more eloquently than i could probably do set out the other elements of his design namely that he then specified um
01:07:02 namely that he then specified um the fans which provided considerable uplift to the volumetric extract rate and perhaps if i just highlight a couple of figures here to achieve 2.0 meters per second
01:07:15 to achieve 2.0 meters per second the volumetric extract rate required was 3.2
01:07:19 3.2 cubic meters per second mr marnie added 50 percent on top of that to give an extract rate of 4.8 cubic meters per second
01:07:33 another margin of comfort was added because the fan specification increased that further to 5.6 cubic meters per second
01:07:45 cubic meters per second we submit that that gives considerable robustness to this system as designed by mr mani
01:07:57 by mr mani on any view we submit this was a significant improvement on the extract rate of the existing system which was calculated by max fordham
01:08:07 fordham at between 1.1 and 1.2 cubic meters per second
01:08:17 i turn briefly to escape phase firefighter phase of what's required and actually this is something that the inquiry may want to think about carefully as it hears the evidence
01:08:28 carefully as it hears the evidence in the means of escape phase the scenario that a smoke control system is required to meet is straight forward the bar is not set high however it's less clear what is required of a
01:08:39 it's less clear what is required of a smoke control system during the fire fighting phase in a residential building such as the tower this is because of the guidance in paragraph 17.14
01:08:50 paragraph 17.14 of the adb which in respect of a residential building results in the position whereby the means of escape measures would generally be adequate for
01:09:01 would generally be adequate for firefighting access so what does that mean well the sca guide notes that there is often confusion regarding firefighting stairs in residential
01:09:12 firefighting stairs in residential buildings but this is the important point there is no requirement for a dedicated firefighting lobby
01:09:19 lobby and the more onerous ventilation recommendations for a firefighting lobby do not apply that's been played in the report of miss menses accepted and adopted in the bsr
01:09:31 menses accepted and adopted in the bsr team to written submissions of paragraph section 25
01:09:37 it follows that a designer may do the bare minimum because the normal lobby of installation for the means of escape will generally be adequate however mr mani did not do the bare minimum
01:09:48 minimum he looked to do better by specifying for the system volume extract rate associated with a velocity flow rate of at least two meters per second through the open stair door
01:09:59 stair door in the circumstances as set out in his technical submission
01:10:06 eighth question would the system make lobby conditions unacceptably worse by drawing smoke from a far flat
01:10:18 dr lane suggests mr mani's design presented some unique hazard because it ran the risk of drawing smoke from the far flat into the lobby during firefighter operations when both
01:10:30 during firefighter operations when both the stair
01:10:31 the stair and the firefly door was opened when a window in the flat is also open dr lane criticizes psp's design for not considering how the loss of the pressure differential might affect the tenability
01:10:44 differential might affect the tenability of the lobby space in circumstances where pressure difference between the stair and the lobby
01:10:49 lobby will reduce as both spaces are directly connected to the outside we've set out our response to this in paragraphs 86 to 98 of our opening
01:11:02 in short that which dr lane identifies is actually not a unique hazard during the firefighting operation the system will extract smoke from the lobby
01:11:13 system will extract smoke from the lobby at full capacity as the pressure differential between the lobby and stair would necessarily be lost
01:11:20 lost smoke will pass into the common lobby once the fire flat door is opened but this is part of the system's design condition it categorically is not the design oversight the system will
01:11:32 the design oversight the system will so far as it reasonably can operate to control the smoke during that phase chairman this is acknowledged and accepted by miss menzies
01:11:43 accepted by miss menzies who explains that the open door allows smoke to pass into the cotton lobby during the fire fighting phase but critically and if i may respectfully
01:11:54 but critically and if i may respectfully say so
01:11:55 say so most importantly miss menzies further says that it is recognized that at this time the only smoke control system
01:12:04 system likely to deter smoke from passing into the stair
01:12:08 the stair through the open stair door is a full pressurization systems other systems ms menzies says will only be able to reduce or minimize the amount of smoke entering
01:12:20 or minimize the amount of smoke entering the stair
01:12:23 the stair a full pressurization system was simply not
01:12:26 not reasonably practical in the context of guitar
01:12:30 guitar my ninth question
01:12:35 did the system meet the functional requirements as designed and as installed as you can appreciate my answer to this is very short
01:12:44 short yes it did and if i may mr chairman just give you the reference for the relevant paragraphs in ms menses report it's paragraph
01:12:52 paragraph 25 26
01:12:55 25 26 220 and 221
01:13:06 mr chairman um given what has been said in the written and oral openings um but still i promise you honoring
01:13:13 honoring um what i said about not using this opportunity to give expert evidence there are a couple of more topics that i might um beg or to steal a little bit more time that
01:13:24 or to steal a little bit more time that i can make some submissions to you on those i promise to be as efficient as i as i reasonably can well we'll be uh indulgent to you as
01:13:35 well we'll be uh indulgent to you as long as you don't overstep the mark
01:13:39 consider that fair warning heeded i shall keep the list um short the first one really is an important one i think i need to say something about the
01:13:50 the lobby aovs which are also referred to as the dampers
01:13:55 now it's a source that obviously that psb selected the lowest possible damper standard
01:14:01 standard which was an egregious failure of particular causative elements our position is that actually that is a misconceived submission because it's premised on an incorrect
01:14:12 because it's premised on an incorrect interpretation of the relevant guidance and industry practice by dr lane in relation to this particular piece of equipment
01:14:22 equipment now the panel will be mindful please of the fact
01:14:25 the fact that all lobby dampers leak the degree to which they leak and whether such leakage falls within acceptable parameters or is undue
01:14:37 acceptable parameters or is undue leakage
01:14:38 leakage is actually the relevant question now the sca guide 2012 provided relevant guidance to psp at the time when the lobby aovs were specified
01:14:52 section 8.2 which provided that guidance included this very first sentence no formal product standard exists
01:15:05 no formal product standard exists for the use of these products in this application no formal product standard exists that sentence is nowhere
01:15:16 nowhere in the hundreds of pages of dr lane's report
01:15:21 now reflecting the lack of a formal product standard for aovs in this application section 8.2.5 of the sca guide
01:15:32 section 8.2.5 of the sca guide listed a range of potentially appropriate standards dr lane rejects and discounts this guidance provided by the sca
01:15:43 guidance provided by the sca on the basis that the guidance was unique and not carried over to the sca guide of 2015. mr chairman i can be blunt the sca guy is
01:15:55 i can be blunt the sca guy is universally accepted industry guidance it's guidance which expressly recognized that there was no formal product standard and therefore set out some acceptable options
01:16:09 in any event that guidance actually isn't unique and mr chairman for your note you'll need perhaps um familiarize yourself with bs triple nine one
01:16:19 nine one 2011 and bs triple nine one two thousand and fifteen
01:16:27 i'm going to give you what were the maximum committed leakage rates for dampers in these documents
01:16:34 documents the maximum leakage rate in bs triple nine one
01:16:38 nine one 2011 was 200 cubic meters per hour per square meter in the 2015 edition
01:16:46 edition this is the key point that had increased to 360 cubic meters per hour per square meter
01:16:59 again just for your note that figure of 360
01:17:04 360 cubic meters per hour per square meter was included in the 2015 edition of the sca guide now please mr chairman note that
01:17:15 guide now please mr chairman note that in
01:17:16 in ignoring the above dr lane proceeds to consider the suitability of the lobby aov
01:17:22 aov specified by psb by reference to the maximum leakage rate of 200 cubic meters per hour per square meter
01:17:33 now next week you're going to hear from a witness from gilbert's and you've already heard that the specified damper was the gilbert series 54 dampers
01:17:44 was the gilbert series 54 dampers you'll look at the project product literature next week and you'll see that the description of those dampers was smoke evacuation dampers
01:17:52 dampers fully tested to the requirements of bsen 1366-2 offering a low leakage rate and particularly suited for smoke
01:18:05 and particularly suited for smoke evacuation shafts and risers in multi-storey buildings obviously mr mani um specified those dampers
01:18:14 dampers accordingly
01:18:23 bearing in mind the warning you gave me mr chairman i'm going to get to the point
01:18:28 point yeah i think so because you've had nearly 10 minutes over time i know i know but please just bear with me let me get to the point dr lane has looked at the test data
01:18:41 dr lane has looked at the test data for the gilbert's 54 dampers and produced a calculated volume flow rate graph
01:18:48 graph now the dampers far test leakage rate was less than 200 cubic meters per hour for the significant majority of the
01:18:59 for the significant majority of the first
01:19:00 first hour of the test and dr lane's view is this
01:19:04 this that the cumulative leakage of this damper
01:19:07 damper was in fact lower than that with a constant leakage of 200 cubic meters per hour per square meter now we recognize that the test was not
01:19:19 now we recognize that the test was not in accordance with bsen13c and it's certainly not part of my instructions to diminish the importance of testing at all however my point is this the fact that
01:19:31 however my point is this the fact that the cumulative smoke leakage from that damper
01:19:34 damper was found to be less than 200 cubic meters per hour square meter in the test must be clearly relevant
01:19:43 relevant when the inquiry is asked to consider whether in fact there was likely to be any undue leakage from closed lobby aovs of this kind in stores in the top and i
01:19:54 of this kind in stores in the top and i haven't even referred you back to the increased permitted limit of 360 by 2015.
01:20:06 mr chairman i've said that in relation to the events of the night i'm going to have to
01:20:11 have to leave that for today painful though it is because i would like the opportunity to consider dr lane's report so i am going to come back to that and i'm afraid i'm just going to ask for your forbearance in that regard
01:20:23 your forbearance in that regard so can i please go to some concluding remarks
01:20:26 remarks these are very short and will not take long at all psv refutes um the suggestion that um this aspect of the refurbishment
01:20:39 that um this aspect of the refurbishment project is to be allied with the rest of the refurbishment work undertaken at the tower
01:20:46 the tower in a narrative of systemic failure characterized by deliberate non-compliance as was urged this morning and in writing by
01:20:57 by friend miss barwise queen's council on behalf of
01:21:00 behalf of bsr team 1. such a submission is we suggest inherently undermined by the fact that the inquiry already has before it
01:21:10 it the report of miss menzies who far from deliberate non-compliance finds that the psp designs satisfy the relevant aspects of requirements b1
01:21:21 the relevant aspects of requirements b1 and b5
01:21:22 and b5 of the building regulations it follows doesn't it mr chairman that the issue is already joined as between experts to the inquiry and the topic of smoke control if i may
01:21:34 and the topic of smoke control if i may respectfully say so is not one which lends itself to a service headline summations i know they are popular but surely the work
01:21:44 work and your work is more important than that
01:21:48 that i i do regret that some have also at least in their written submissions sought to assert that any failings in the design and commissioning of the system were
01:21:59 commissioning of the system were contributive to the unnecessary loss of life
01:22:03 life that was as stated by mr stotton in his written opening for bsr team 2 in paragraph 83. respectfully that does not appear to be
01:22:14 respectfully that does not appear to be supported by the evidence as it is now and we suggest that that kind of
01:22:19 kind of a broad brush summation might not be helpful to you as you set out to take further evidence on these matters
01:22:29 mr chairman finally may i just um say this that as the inquiry proceeds to consider
01:22:36 consider the topic of smoke control and hear the evidence
01:22:40 evidence psb would respectfully ask that the inquiry
01:22:44 inquiry ensure that its work remains scrupulously objective firmly evidence-based proportionate and fair bearing in mind that the system
01:22:56 and fair bearing in mind that the system as i said at the beginning as one of my nine initial points was designed for a fire in a single flat on one floor only not to cope with the
01:23:07 on one floor only not to cope with the undeniable catastrophic cladding fun and its many overwhelming consequences that transpired at the turn on the 14th of june 2017.
01:23:20 on the 14th of june 2017. may thank you because i did steal more time
01:23:23 time than i said i needed but um i'm thankful for your patience and your forbearance in allowing me to make submissions on behalf of my clients right well thank you very much mr
01:23:34 right well thank you very much mr bennett um you were lucky that we had a bit of time to play with this morning so um we were quite willing to let you make the points that you wanted to make but thank you very much indeed
01:23:46 but thank you very much indeed thank you mr chairman and uh now i'm going to invite mr martin seaword to make some uh an opening statement on behalf
01:23:56 behalf of the fire brigades union mr c with you there
01:24:01 there i am well first thing i should do is to say good morning and to apologize for having kept you waiting but i think if you've been following the proceedings you'll know that we were persuaded to be a bit indulgent
01:24:13 persuaded to be a bit indulgent to mr bennett but there it is anyway now is your opportunity to make your opening statement and we look forward to hearing from you thank you thank you mr chairman well
01:24:25 thank you thank you mr chairman well uh good morning sir martin and fellow panel members and assessors the fbu and those it represents remain humbled by the suffering caused by the grenfell tower disaster and committed to
01:24:37 grenfell tower disaster and committed to a full
01:24:37 a full and open inquiry starting with the relevant time the smoke control system is directly relevant
01:24:46 relevant to the early stages of the fire dr lane reported in section 12 of her smoke control
01:24:51 control report it is reasonable to assume as per my phase one report that from 126 the single floor design condition had been exceeded and therefore the system could no longer
01:25:03 and therefore the system could no longer be reasonably expected to provide protection to the protected steer against increasingly substantial smoke spread from multiple lobbies it follows that deficiencies in the
01:25:14 deficiencies in the smoke control system are only directly relevant in the early stages of the fire up to about 130. thereafter the total building failure due to the widespread breach of compartmentation outside and inside the tower produced
01:25:27 outside and inside the tower produced more toxic smoke than any smoke control system was designed to expel indirectly however these deficiencies contributed to the breach of compartmentation inside
01:25:39 to the breach of compartmentation inside the tower
01:25:40 the tower as i will explain
01:25:43 turning to the need for a smoke control system steer and ventilate and lobby ventilation were active fire protection measures which were essential parts of the package of measures to support means of escape and firefighting in a
01:25:55 of escape and firefighting in a high-rise residential building even with a staple strategy which requires a terrible need to escape for anyone affected by heat smoke or fire
01:26:04 fire and who therefore has to leave the building
01:26:07 building in her smoke control report dr lane concluded the fundamental purpose of the design
01:26:12 design of any mechanical smoke ventilation system for grenfell tower was therefore to maintain terrible conditions for means of escape in the extended trouble of the internal conditions for means of escape and
01:26:23 conditions for means of escape and firefighting in the stair this need was accentuated by the use of combustible materials in the rain screen cladding system although this increased risk of rapid
01:26:34 although this increased risk of rapid fire spread generating blinding clouds of toxic smoke
01:26:38 smoke does not appear to have been considered by those designing installing commissioning or approving the refurbished smoke control system dr lane's conclusions in summary
01:26:50 dr lane's conclusions in summary she's concluded that the refurbished vote control system did not achieve this purpose focusing on the early stages of the fire dr lay reported at 1 25 smoke was observed to spread
01:27:03 at 1 25 smoke was observed to spread from the level 4 lobby to the protected stair to the open stair door therefore the stated primary objective of the smoke control system design failed at this time ultimately
01:27:15 design failed at this time ultimately the evidence she went on ultimately the evidence shows that by 125 the system had already failed in its primary function
01:27:22 function which psb had defined as providing protection to the stair from smoking the level 4 lobby with all flat entrance doors closed the design of the lobby smoke control
01:27:35 the design of the lobby smoke control system at grenfell tower did not comply with the original performance standards set out in cp3 1971 or the performance stands documented by the secretary of state
01:27:46 documented by the secretary of state in adb 2013. i've given the references to these
01:27:51 to these citations and the written submissions and don't repeat them here the lobby smoke control system designed and installed at grenfell tower did not comply with the functional requirements of schedule 1 the building regulations uh 2010
01:28:04 the building regulations uh 2010 b1 b3 and b5 when handed over to kctmo these conclusions are all challenged by those involved in the refurbishment of the state control system
01:28:14 system before the fire but dr lane's conclusions appear to be sound and reliable and are supported by the evidence from phase one accepted by the chairman
01:28:27 from phase one accepted by the chairman the panel will need no reminding that this was a critical period in fact uh stephanie baldwin's qc has already reminded the panel uh a critical period up to about 1 30 a.m when
01:28:38 a.m when a significant number of residents were deterred from exiting the building due to smoke logging in the logging in the lobbies and when the lifts were filled with thick black choking smooth
01:28:49 choking smooth the chairman found in his phase one report by around 1 30am on the night there was evidence of smoke affecting the lobbies on 14 floors of the tower with heavy or significant smoke blocking on eight
01:29:01 significant smoke blocking on eight floors
01:29:03 floors uh 5 6 8 10 11 12 15 and 16 and at least light smoke also reported on the other six floors 14 17
01:29:14 reported on the other six floors 14 17 19 21 22 and 23. there may have been more uh we're going to look at in exa in a moment at the example of petrodullova on floor
01:29:25 petrodullova on floor 20. two brief examples of difficulties traveling through the lobbies around about that time show why a smoke control system is so important in a high-rise residential
01:29:36 important in a high-rise residential building
01:29:37 building and maybe irrelevant when the panel considers whether the travel distance through the lobbies was more than 10 meters as dr lane reports or less than 10 meters as psb contends
01:29:49 or less than 10 meters as psb contends so the first of these examples petroglover was on floor 20. the chairman reported at paragraph 11 point
01:30:00 paragraph 11 point 51 in chapter 11 of volume 2. the couple the couple gathered wet towels and collected their pre-packed bag
01:30:08 bag petro delova told me that she was astounded by what she saw on opening her front door closing the door she returned to the kitchen window for air
01:30:17 for air before attempting to leave again when she left
01:30:20 she left petra deliver found the lobby to be pitch black and full of really horrible what felt like toxic smoke and the sound was very strange as well it was kind of like weird low humming strange sound
01:30:31 strange sound using her hands petrov felt her weight in stair door at one point she encountered the locked cupboards opposite the lifts which she mistook
01:30:40 mistook for that door it clearly wasn't a straight
01:30:43 straight run from her door to the to the stair to the door to the stairs
01:30:52 edward defon the second example he was on uh floor 16 and i won't go into detail but the chairman reported at paragraph 11.81 that he also struggled to find the
01:31:03 that he also struggled to find the stairway door the smoke clogged state of the lobbies at this time shortly before 1 30 demonstrate that the smoke control system did not perform as intended on the night
01:31:14 perform as intended on the night even before it was overcome by total building failure this evidence substantiates the conclusions of dr lane referred referenced above
01:31:24 the contribution of the smoke control system
01:31:28 system or the deficiencies in the smoke control system refurbishment to to com to the breach of compartmentation as to the south shaft of the smoke control system smoke was observed leaking through closed dampers into the
01:31:40 leaking through closed dampers into the lobbies on levels 6 20 and 23 in the early stages of the fire prior to 1.33 suggesting that the stack effect was enabling smoke to spread up the south shaft at this time
01:31:51 shaft at this time providing further evidence that the level 2 extract system was not operating as intended dr lane concluded it's probable that the level two extract system ceased to function in the early stages of the
01:32:02 to function in the early stages of the fire
01:32:02 fire enabled smoke to rise from level four and then when the other dampers opened smoke from other levels also to enter the south shaft and rise up through the south shaft
01:32:13 and rise up through the south shaft she considers the performance of the south shaft in the early stages of the fire most likely enhance the flow of smoke from the south shaft
01:32:22 shaft through the dampers into the upper lobbies of the tower as to the north shaft dr lane considers it likely that two sets of dampers in the north shop were probably open simultaneously
01:32:33 simultaneously in the early stages of the fire up to 1 30 and that performance of the north shaft was a significant breach of compartmentation as the dampers failed to shut when the fire commenced
01:32:44 fire commenced as based on the bre investigation and therefore failed to provide the required integrity to maintain the performance of a protected child the failure of the north shore constitutes an overall failure to comply
01:32:56 constitutes an overall failure to comply with functional requirement b3 um b3 open brackets three close breakers because as a result the compartmentation to each lobby at chromophil tower from the floor of far origin to the top
01:33:08 from the floor of far origin to the top of the building was not provided dr lane has concluded that
01:33:13 that damper leakage and smoke control system performance issues contributed to conditions in the lobbies of grenfell tower coupled with the failure of level 11 dampers in the north shaft to close it
01:33:24 dampers in the north shaft to close it at 55 minutes past midnight as was required
01:33:29 required these conditions would also result in the airflow velocity through the level 4 steered or failing to meet the required design velocity in the early stages of the fire she considers the evidence of how the smoke
01:33:40 considers the evidence of how the smoke control system of grenfell tower was designed installed commissioned to maintain to be another example of a failure by apparently competent persons to provide a fire safety system that relevant persons and the
01:33:51 that relevant persons and the firefighters could depend upon to to rely to work reliably
01:33:57 reliably in the event of fire now this gives rise to a wider question and the fbo invites the panel to ascertain the underlying reasons
01:34:04 reasons why apparently competent persons fail to think fast efficiently or at all a persistent theme throughout the grenfell target and specifically to consider whether the
01:34:16 and specifically to consider whether the cumulative effects of 15 years of austerity cuts and deregulation materially contributed to the culture of minimal
01:34:23 minimal or non-compliance turning then to max fordham's motivation to consult psb in november 13 they were consulted very early in in in
01:34:34 they were consulted very early in in in this story max ford approached the proposed refurbishment of the original system to achieve a mechanical smoke extract system supplying fresh air from the
01:34:45 system supplying fresh air from the south shaft and exhausting smoke from the north shore but they were unable to demonstrate this was no worse than existing as the existing system wasn't working additionally there was no evidence of
01:34:57 additionally there was no evidence of any analysis of any original standard to establish the original core performance objectives unsurprisingly it got complicated with building control and according to matt cross smith of max
01:35:09 and according to matt cross smith of max fordham
01:35:10 fordham max fordham therefore got in touch with psb
01:35:14 psb accordingly the fbi asks whether the motivation to consult psp was to get the refurbishment past building control rather than aiming for fire safety if so
01:35:25 rather than aiming for fire safety if so this is further event of the minimum compliance culture so prevalent in the refurbishment of the tower
01:35:32 tower and yet another contractor's misplaced dependency on building control control approval turning into design flaws and and appreciating that this is contentious
01:35:44 appreciating that this is contentious dr lane described fundamental flaws in psb's design of the smoke control system for the refurbishment these have been summarized in our written opening submissions on smoke
01:35:55 written opening submissions on smoke control and expertly described by adrian williamson qc and stephanie barwise qc this morning so i do not repeat them here mainly highlight one aspect notwithstanding the smoke control
01:36:06 notwithstanding the smoke control association's guide which requires the designer to consider the effects in a fire e.g occupants making their escape and fire fighting and thus different arrangements of open and closed doors
01:36:19 arrangements of open and closed doors and fire behavior at different times in a fire event bsb's approach failed to give
01:36:25 give any or adequate consideration to the likely range of events which might occur in a fire dr lane found conditions up to 1 30 am were entirely
01:36:36 conditions up to 1 30 am were entirely foreseeable she said i do not consider the fire conditions affecting the level four lobby before 130 nor the escape activity or firefighting activity during that time period
01:36:47 activity during that time period to be anything other than reasonable and entirely foreseeable she also said the failure of the smoke control system as it was designed was caused by the entirely expected condition of more than one door being
01:36:59 condition of more than one door being open
01:37:00 open to the level 4 lobby when the firefighters were fighting the fire in flat 16.
01:37:06 flat 16. notwithstanding it was entirely expected this eventuality should have been but was not catered for in psb's design of the smoke control system installed at grenfell tower in the course of the refurbishment
01:37:19 course of the refurbishment will doubtless consider whether and if so how mr mani took into account that the normal and expected firefighting procedure in a high-rise residential building required multiple doors to be propped
01:37:30 required multiple doors to be propped open in order to lay two jets one for the b18 fighting fire and far flat and one for the ba back up team and so as a minimum to run a jet from the rise dry riser outlet on the floor below the
01:37:42 dry riser outlet on the floor below the far
01:37:42 far far flat up to the far flat thereby propping open at least three doors the door from the lobby to the stairs on the floor below the door from the stairs to the lobby on
01:37:53 the door from the stairs to the lobby on the far floor and the flat the fire flat entrance door the the fbu submits that fire fighters cannot properly be blamed for any fire spread by fire fighting or smoke spread by fire fighting in the
01:38:05 or smoke spread by fire fighting in the early stages of the fire we should have been but was not allowed for in the design of the refurbished smoke control system as to using the controls
01:38:16 system as to using the controls uh in in your phase one report mr chairman
01:38:19 chairman at volume two paragraphs fourteen six to fourteen
01:38:22 fourteen eight you noted that soon after two am on the night of the fire station manager walton and watch manager dalton had approached the smoke control panel on the wall in the ground floor lobby
01:38:33 on the wall in the ground floor lobby that station manager walton remembered previously attending a demonstration of the controls and asked watch manager dalton to see if it was working the chairman further noted that watch manager dowden chose not to actuate
01:38:45 manager dowden chose not to actuate the manual override and told station manager walton that the smoke control system was not working as a result of this exchange station manager walton decided that the nfp could not rely on any of the systems in
01:38:57 could not rely on any of the systems in the building dr lane's conclusion in her smart control report showed that watch manager dowden's assessment was correct additionally she considered the instructions provided to the fire service
01:39:08 service including the demonstration which station manager walter made earlier attended
01:39:13 attended were wholly inadequate to allow attending firefighters to understand the full complexity of the system and i've given the reference in the written submissions the fbu submits that in these circumstances
01:39:24 in these circumstances no blame attaches to the firefighters for deciding not to try to take control of the system at this or any earlier stage of the fire
01:39:34 the refurbishing companies complain of inadequate time to prepare they complain they've only recently seen dr lane's threat control report
01:39:43 report thereby placing their witnesses in difficulty the fbu has no sympathy for these complaints four years have passed since the tragedy and their witnesses have had access to
01:39:54 and their witnesses have had access to their lawyers throughout that period by contrast and out of a sense of civic duty
01:40:00 duty firefighters and control room staff went into the witness box in phase one without sight of any expert reports without any discussion about the evidence with their lawyers and without any undertaking given by the
01:40:11 and without any undertaking given by the attorney general turning now to the conclusions
01:40:18 that we seek to make at this stage in in light of dr lame smoke control report the fbu invites the inquiry to conclude that firefighting activities were entirely as expected in
01:40:29 activities were entirely as expected in the early stages of the fire and should should have been allowed for in the design of the stroke control system but but not the failings in design commissioning installation and maintenance and smoke control system materially contributed to
01:40:41 control system materially contributed to the total failure of compartmentation inside the tower and together with the failures of the other active and passive fire protection systems inside the tower dry not wet riser fire doors many not
01:40:53 dry not wet riser fire doors many not self-closing or fire resistant fire control switch not operable so the lifts could not be used for firefighting or evacuation covered and unclear floor numbering in the stairs and lobbies
01:41:04 the stairs and lobbies the emergency lighting not working properly made the work of the firefighters much more difficult we would say impossible thank you for this opportunity mr chairman that
01:41:15 for this opportunity mr chairman that concludes
01:41:17 concludes our oral submissions well thank you very much mr seaworth that concludes the oral opening statements in relation to smoke control system so we shall
01:41:30 smoke control system so we shall rise at that stage and resume tomorrow at 10 o'clock when we shall hear the first witness on this particular topic so 10 o'clock tomorrow please thank you
01:41:41 so 10 o'clock tomorrow please thank you very much
01:41:54 you