Grenfell Tower Inquiry: Phase 2 Report · 2024
Chapter 39: Response to fire risk assessments
Chapter 39: Response to fire risk assessments
The duty to record significant findings
¶39.1 Article 9(6) of the Fire Safety Order requires the responsible person to record certain information, including the significant findings of the assessment and the measures which have been or will be taken by that person pursuant to the order.751 Fire Safety Order {BEI00001545/8} Article 9(7).
¶39.2 Guidance on carrying out fire risk assessments was published by the British Standards Institution in the form of Publicly Available Specification 79 (PAS 79). It represented current best practice in the industry. The edition of PAS 79 relevant to the fire risk assessments carried out in relation to Grenfell Tower by Carl Stokes (other than that carried out in December 2010) was PAS 79:2012. We therefore refer mainly to that edition in this section of the report.
¶39.3 Clause 19 of PAS 79:2012 provided guidance on the formulation of an action plan.752 PAS 79:2012 {CTA00000003/59-60} clause 19; Similar guidance is provided in PAS 79:2007 {CTA00000001/55-56} clause 18. It recommended that every documented fire risk assessment should incorporate an action plan such as to ensure that, if implemented, it would reduce the fire risk to, or maintain it at, a tolerable level.753 PAS 79:2012 {CTA00000003/60} clauses 19.1 and 19.2; PAS 79:2007 {CTA00000001/56} contains identical provisions at clauses 18.1 and 18.2. The commentary on Clause 19 stated that it was normally appropriate to allocate a priority to each measure recommended and gave an example of a scheme of prioritisation.754 PAS 79:2012 {CTA00000003/59-60} paragraphs (vii) to (xiv); PAS 79:2007 {CTA00000001/56-57} contains similar provisions.
¶39.4 In addition to the guidance, the annexes to PAS 79:2012 contained model documents available for use by fire risk assessors.755 PAS 79:2012 {CTA00000003/77-99}; PAS 79:2012 {CTA00000003/106-113}; Similar templates were included in PAS 79:2007 {CTA00000001/59-80} Annex A; PAS 79:2007 {CTA00000001/85-94} Annex D. Annex B contained a template that could be used for an initial fire risk assessment and Annex E provided a shorter template for a review of an existing fire risk assessment.756 PAS 79:2012 {CTA00000003/77-99} Annex B; PAS 79:2012 {CTA00000003/106-113} Annex E; PAS 79:2007 {CTA00000001/59-80} Annex A; PAS 79:2007 {CTA00000001/85-94} Annex D. It included prompts for the assessor to record any significant changes in the management of fire safety since the previous fire risk assessment.757 PAS 79:2012 {CTA00000003/111} Annex E. At the end of each template PAS 79:2012 included a basic pro forma action plan.758 PAS 79:2012 {CTA00000003/98-99}; PAS 79:2012 {CTA00000003/112-113}; PAS 79:2007 {CTA00000001/80}; PAS 79:2007 {CTA00000001/93-94}. Both of the PAS 79:2012 action plan templates provided space for recording the actions to be taken by the responsible person in a table that contained columns for priority, the identity of the person by whom action was to be taken and the date on which it was taken. They also contained sections for the assessor to indicate the overall level of fire risk that would be achieved once all the actions identified had been completed. In addition, the template for a fire risk assessment review included a section prompting the assessor to enter details of any actions identified on a previous occasion that had not been carried out by the time of the review.759 PAS 79:2012 {CTA00000003/113}; PAS 79:2007 {CTA00000001/93}.
88¶39.5 The TMO's fire safety strategy in force from November 2013 recorded that the LFB's Fire Safety team had been told that the assessment to be produced by the TMO's consultant would be based upon the pro forma in PAS 79.760 TMO Fire Safety Strategy dated November 2013 {TMO00830598/9} paragraph 14.1.3.
¶39.6 In their fire risk assessments produced for the TMO, Salvus and Carl Stokes both included a schedule setting out their significant findings and providing a plan for any necessary remedial work. However, although the purposes of the schedules were the same, the contents and approaches differed.
¶39.7 Salvus's action plan was incorporated in the risk assessment as part of a single document.761 Salvus FRA and Action Plan for Grenfell Tower dated 30 September 2009 {CST00003128}. That was necessary, because the action plan did not repeat the findings in the assessment that required remedial action. Instead, it referred to them using the item number in the assessment. In addition to setting out the action which needed to be taken, Salvus identified the time within which it should be taken. Space was provided to record the name of the person responsible for carrying it out and the date by which it should be completed. A colour-coded column indicated whether the action related to a statutory breach, was required to conform to best practice or guidance, or was simply recommended by the assessor. A column was available to record the name of the person carrying out a re-assessment. Finally there was a column to record any change in the level of risk.762 Salvus FRA and Action Plan for Grenfell Tower dated 30 September 2009 {CST00003128/15-19}. However, the form did not make provision for recording the overall risk to the premises once all the actions had been completed, as suggested by the template in PAS 79:2012. It also did not include a section relating to actions outstanding from previous assessments.
¶39.8 The format in which Carl Stokes produced his fire risk assessments was different. The schedule of significant findings did not form part of the assessment itself but was contained in a separate document described as a "Record of Significant Findings and Action Plan".763 Record of Significant Findings and Action Plan for Grenfell Tower dated 29 December 2010 {CST00003165}. His form differed from that used by Salvus in that, as well as cross-referring to the section of the assessment which identified necessary remedial action, it also repeated the description of the risk or hazard that had been identified. It indicated the priority to be given to each action, whether high, medium, or low, with colour-coding, although without a key to explain the classification. At the head of the document there was an indication of the time within which each category of remedial measures needed to be completed. The form also provided sections in which the identity of the person or department responsible for carrying out the work and the date by which it needed to be completed could be recorded.
¶39.9 In contrast to the pro forma at Annex E of PAS 79:2012, Carl Stokes's form did not contain a section for the assessor to record any actions that had not been completed since the last inspection, nor did it contain an indication of the level of risk to the premises once the actions identified had been completed.
¶39.10 Carl Stokes understood that his form of risk assessment and Record of Significant Findings and Action Plan had been shown to and approved by the LFB.764 Stokes {Day137/36:11-13}; Specimen FRA and Action Plan {CST00003071}; {CST00003089}.
89Carl Stokes's practice
¶39.11 Carl Stokes said that when he identified concerns in the course of a fire risk assessment, he recorded them in the schedule of significant findings and assigned a priority for their completion.765 Stokes {CST00003063/19} page 19, paragraph 55(iv); Stokes {CST00003063/23} page 23, paragraph 68. He said that the document had been set out in that way to allow the TMO to use it as a checklist to ensure that all the points raised had been dealt with.766 Stokes {CST00003063/23} page 23, paragraph 68.
Subsequent inspection of premises
¶39.12 In his written statement Mr Stokes said that when he made subsequent visits to premises in order to conduct a fire risk assessment he would take with him the schedule of significant findings produced following his previous visit, which he would use as a starting point to ensure that all the points raised had been dealt with.767 Stokes {CST00003063/23} page 23, paragraph 68. That approach, had he actually adopted it, would have been in accordance with the guidance in clause 20 of PAS 79:2012, which advises that when a fire risk assessment is reviewed, consideration should be given to the extent to which the original action plan has been implemented and work that has not been completed identified.768 PAS 79:2012 {CTA00000003/61} paragraph 20(v). Carl Stokes confirmed that he was aware of this advice, Stokes {Day137/55:20-23}.
¶39.13 However, we doubt that he did in fact adopt that approach. Although the annotated copies of his significant findings and action plans for Grenfell Tower made in October 2014 and April 2016 contain his manuscript annotations,769 Handwritten notes on 2014 FRA Significant Findings Schedule {CST00003151}; Handwritten notes on April 2016 FRA Significant Findings Schedule {CST00000003}. there is no reference in any of his fire risk assessments or action plans to any outstanding (or indeed, completed) work that he had identified as necessary during a previous assessment.
¶39.14 When he gave evidence Carl Stokes said that it was his practice to ask Janice Wray to provide him with a printed copy of the previous fire risk assessment from which to work.770 Stokes {Day139/103:22}-{Day139/104:4}. He said that by comparing the state of the premises during his inspection with the records of his previous inspection, he could see that recommendations he had made on a previous visit had not always been completed, but he did not have any idea of the total number of recommendations outstanding at any time.771 Stokes {Day139/103:16-21}. Mr Stokes told us that he had raised the importance of completing actions during meetings with Janice Wray, but there is no record of any of those meetings.772 Stokes {Day139/104:5-21}. The TMO therefore had no reliable or comprehensive record of what remedial work Mr Stokes thought it particularly important to complete.
The involvement of the TMO's Health and Safety team
¶39.15 Once the information had been put on to the relevant TMO system, it could be distributed to the teams whose responsibility it was to carry out the work. It was primarily Janice Wray's responsibility to allocate the remedial work to the appropriate team in the TMO.773 Wray {Day141/33:20}-{Day141/34:8}.
90¶39.16 The way in which the information was recorded and processed by the TMO changed over time. From October 2010, the work was recorded in electronic spreadsheets and documents.774 Wray {Day141/25:10-18}. The documents contained information which appeared to have been copied from various different Action Plans and pasted into the document.775 See Composite FRA (High Risk) Action Plan Items for response repairs for Grenfell and other TMO stock {TMO10002330}. From August 2013, the TMO began to use a computerised system for logging recommendations. This system, known as "W2", was a database in which recommendations were recorded and by which work could be assigned to the appropriate team for completion within a given time.776 Wray {TMO00000890/33-34} pages 33-34, paragraph 148. When a job was assigned to a team, it would appear in that team's general "inbox" on the W2 system, along with any other tasks assigned to it.777 Wray {TMO00873629/17} page 17, paragraph 71. When a team had completed the work assigned to it, it could mark the tasks as complete and Janice Wray or one of her assistants would then close them.778 Wray {TMO00000890/33-34} pages 33-34, paragraph 148; Wray {TMO00873629/16} page 16, paragraph 65. When the W2 system was first introduced, it ran in parallel to Janice Wray's spreadsheet tracker until all the actions recorded in the spreadsheet had been completed. At that point the spreadsheet was closed.779 Wray {Day141/27:10-20}. On 25 May 2016, the TMO launched a new system, which took over the electronic processes for recording and monitoring remedial work. However, the TMO Health and Safety team did not use that system to record remedial work until about a week before the Grenfell Tower fire.780 Wray {TMO00873629/17} paragraph 70.
¶39.17 Where remedial work was assigned to the TMO Health and Safety team, Janice Wray could give instructions herself to Repairs Direct or the relevant contractor to carry it out. Instructions of that kind were given through the Capita Housing Management System.781 Wray {Day143/197:6-15}; Bowman {TMO00842308/1-2} pages 1-2, paragraph 2.
¶39.18 The methods of recording and monitoring we have described related only to actions recorded in the schedules of Significant Findings and Action Plan produced in the course of fire risk assessments. Any necessary remedial work identified by other means, for example by the LFB in a deficiency notice, was not recorded in or monitored using the electronic systems. We describe below how they were handled.782 Wray {Day141/222:21}-{Day141/224:11}.
Access to data
¶39.19 Throughout his time as fire risk assessor Carl Stokes was not given full access to relevant fire safety information by the TMO, despite his asking for it. In particular, many of the actions identified in the Significant Findings and Action Plans referred to the need for the TMO to confirm the maintenance of certain items of equipment. For example, in the Significant Findings and Action Plan for Grenfell Tower produced in November 2012, Mr Stokes sought confirmation that the smoke ventilation system was being serviced and maintained in accordance with the manufacturer's instructions.783 Record of Significant Findings and Action Plan for Grenfell Tower dated 20 November 2012 {CST00003083/5} item 23c.
¶39.20 Between 2010, when he began his assessments for the TMO, and October 2015, Carl Stokes had to rely for information about the maintenance and servicing of equipment on records printed out for him by the TMO Maintenance Department or Janice Wray.784 Stokes {Day136/131:15-25}.
91¶39.21 From 2010, the TMO recorded information on servicing and inspection of plant and machinery on a computer programme known as "Keystone".785 Parsons {TMO00870938/1-2} pages 1-2, paragraphs 5-6. Although he had been providing fire risk assessments for the TMO since 2010, Carl Stokes did not have access to the data held on Keystone until October 2015. He was eventually given remote access to Keystone in the hope that he could check for himself that servicing had been carried out and thus reduce the number of recommendations he made in the future.786 TMO Health & Safety Committee Minutes dated 16 April 2015 {TMO10009485/2} item 4.1. In any event, Carl Stokes had access to the Keystone system by the time he carried out the fire risk assessment in April 2016, as he recorded in that assessment that he had checked the Keystone records in relation to certain items.787 Record of Significant Findings and Action Plan for Grenfell Tower dated 26 April 2016 {CST00003098/7-8} item 23a and item 23e.
¶39.22 Even with access to Keystone, Carl Stokes was reliant upon TMO staff for some information because Keystone did not contain maintenance and servicing records for some equipment that was critical to fire safety. In particular, it did not contain maintenance and servicing records for the fire control system, dry rising fire main or emergency lighting system at Grenfell Tower.788 Lane, The Management and Maintanance of Grenfell Tower, Chapter 7, Module 3 Report {BLARP20000033/220} paragraph 11.2.56. Carl Stokes told us that if he could not obtain information for himself, he asked the TMO for the information he needed.789 Stokes {Day136/133:3-19}. If he was still unable to obtain the information, he would record in the Significant Findings and Action Plan that he did not have it.790 Stokes {Day136/133:21-24}.
¶39.23 However, we doubt that he was consistently conscientious in doing so and his requests for information were patchy. Paul Steadman, who was the estates services assistant (ESA) for Grenfell Tower at the relevant time, had no recollection of having been consulted by Carl Stokes in relation to a fire risk assessment,791 Steadman {Day146/84:9-25}. despite the fact that Mr Stokes recorded having consulted him by name in connection with the fire risk assessments for Grenfell Tower carried out in 2010, 2012, and 2014.792 Fire Risk Assessment of Grenfell Tower dated 29 December 2010 {CST00003181/3}; Fire Risk Assessment of Grenfell Tower dated 20 November 2012 {CST00003084/3}; Fire Risk Assessment of Grenfell Tower dated 10 October 2014 {CST00003157/3}. Moreover, Mr Stokes was never given access to the W2 system and was therefore unable to check for himself whether actions which had been identified during his previous visit to a property had been completed. He said that he had been forced to rely on documents printed out by Janice Wray,793 Stokes {Day138/121:5-22}; Wray {Day141/153:9}-{Day141/154:5}. Janice Wray was unable to recall whether she had provided Carl Stokes with spreadsheets from W2. She thought that she had probably done so for blocks in respect of which he had been requesting information, Wray {Day141/153:24}-{Day141/154:5}. but if that was so, it is surprising that they were not mentioned in his fire risk assessments.
The TMO's management of remedial work
¶39.24 Within its sections on formulating an action plan, PAS 79 provides guidance on prioritising actions and the time to be allowed for their completion. PAS 79:2007 provided a scheme comprising three priorities: "immediate", "short term" (within three months), and "long term" (to be carried out as and when the opportunity arose).794 PAS 79:2007 {CTA00000001/55-56} clause 18. PAS 79:2012 also provided a scheme comprising four priorities, which broadly replicated the 2007 scheme publication with the addition of a "medium term" category for implementation within three to six months.795 PAS 79:2012 {CTA00000003/59-60} clause 19(ix). It is clear from the text of both editions of PAS 79 that the intention of the document was that actions were to be completed within the timescales indicated. Both the 2007 and 2012 versions of PAS 79 recognise that other systems of prioritisation could be adopted, including a system which distinguished between items which breach legislation and those which do not.796 PAS 79:2007 {CTA00000001/56} clause 18; PAS 79:2012 {CTA00000003/60} clause 19(x).
92¶39.25 There were five categories of priority for implementing the remedial measures identified in the action plan produced by Salvus for Grenfell Tower.797 Salvus FRA and Action Plan for Grenfell Tower dated 30 September 2009 {CST00003128/19}. The highest three priorities required action within a short time, ranging from 24 hours to one month. Salvus also included a colour-coded designation, indicating whether an action represented a breach of statute (red), compliance with best practice or guidance (amber) or simply a recommendation (green).798 Salvus FRA and Action Plan for Grenfell Tower dated 30 September 2009 {CST00003128/19}. As such, the colour-coding was not directly related to the priority rating or the time for completion, but it gave a useful indication of the basis of the advice. The risk presented by each item was assessed separately and the action plan included a column for a revised level of risk once the remedial work had been completed.
¶39.26 The Record of Significant Findings and Action Plan for Grenfell Tower dated 29 December 2010 resulted from Carl Stokes's first fire risk assessment of the tower.799 Record of Significant Findings and Action Plan for Grenfell Tower dated 29 December 2010 {CST00003165}. He identified 23 separate risks or hazards, each of which was given a priority rating for completion on the scale "High" (2 – 3 weeks), "Medium" (1 – 2 months) and "Low" (3 – 6 months). He thought that those periods had been agreed between the TMO and the LFB, but Janice Wray could not confirm that and did not believe that a detailed discussion of that kind had taken place.800 Stokes {Day137/36:11-13}; Wray {Day141/53:8-13}. Mr Stokes confirmed that the document required actions to be completed within the periods indicated.801 Stokes {Day137/35:19-25}.
¶39.27 Carl Stokes also included a colour-coded designation of priority in his action plans. The TMO's fire safety strategy of November 2013 referred to that colour-coding as a guide to the priority to be accorded to different actions and explained that, like the Salvus colour‑coding system, red referred to measures required to comply with legal requirements under the Fire Safety Order and any significant risk to life, amber to recommendations relating to good practice and green to actions that would enhance fire safety based on good practice, but of a lower priority.802 TMO Fire Safety Strategy dated November 2013 {TMO00830598/9} paragraph 14.1.3. The fire safety strategy also confirmed that remedial work would be carried out in order of risk, with priority given to items with a red or amber rating.803 TMO Fire Safety Strategy dated November 2013 {TMO00830598/9} paragraph 14.1.3. Unlike the Salvus document, in which the colour-coding indicated the basis of the action and a separate system was incorporated to indicate priority, Carl Stokes's system effectively dealt with both aspects together.804 Under a system of that kind an item identified as a breach of legislation would always be categorised red and be prioritised, regardless of the actual risk it posed. By taking such an approach he conflated the gravity of the risk and the urgency of the work. We agree with Colin Todd that it is generally better to deal separately with the degree of risk and the time for completion of remedial measures, because, for example, it may be possible to eliminate a low risk quickly.805 Todd {Day167/26:21-24}; Todd {Day167/27:9-12}.
93¶39.28 Carl Stokes's form did not include a section for an overall assessment of the risk level once all remedial measures had been carried out, as suggested in Annex E to PAS 79, nor did it include a column for a revised level of risk, as did the Salvus template.
¶39.29 The next Record of Significant Findings and Action Plan for Grenfell Tower is dated 20 November 2012, reflecting Carl Stokes's fire risk assessment of that date. In that document the time within which high priority items were to be completed remained the same as in the 2010 schedule, but the time allowed to complete medium and low priority actions were both increased. In the case of medium priority actions the period of 1 – 2 months was increased to 2 – 3 months; for low priority actions it was increased from 3 – 6 months to 6 – 12 months.806 Record of Significant Findings and Action Plan for Grenfell Tower dated 20 November 2012 {CST00003083/1}.
¶39.30 Carl Stokes thought that he had extended the periods for medium and low priority actions because of relevant guidance, but he was unable to identify it when he gave evidence807 Stokes {Day137/37:19-25}. and none has come to light in any document we have seen. His extended periods did not accord with either the 2007 or 2012 versions of PAS 79. When pressed during his evidence for the specific source of guidance he had relied on to support the change, he suggested that he had taken them from the LGA Guide,808 Referred to elsewhere in this report as the LGA Guide. but that document contained no reference to the extended periods he adopted and provides guidance on the prioritisation of remedial measures only in the broadest of terms.809 Local Government Association Guide "Fire safety in purpose-built blocks of flats" {HOM00045964/47} paragraph 37.1. No other support for his decision has been identified.
¶39.31 The time allowed for completing remedial measures was changed again in the Action Plan for Grenfell Tower dated 17 October 2014.810 Record of Significant Findings and Action Plan for Grenfell Tower dated 17 October 2014 {CST00003177/1}. Although the periods allowed for each category remained the same, there was added in parenthesis after the period of 6 – 12 months relating to low priority work the words "to start to action any works". Carl Stokes confirmed that he intended the qualification to apply to all three priority ratings.811 Stokes {Day137/41:1-5}. The effect of that amendment was that whereas previously the TMO had been required to complete the work within the prescribed periods, it was now required only to have started it within that period. No date for completion was prescribed.
¶39.32 The TMO had not asked for the action plan to be altered in that way.812 Stokes {Day137/41:14-15}; Wray {Day141/61:20-23}. Carl Stokes's explanation was that "companies" had told him that they were encountering difficulties in completing work identified in action plans where they required capital investment which could not be provided at short notice.813 Stokes {Day137/39:12-23}. His reference to "companies" suggests that he understood it to be a problem that had either been raised by a number of clients or was widespread and well-known within the industry. However, neither of the experts who considered the matter thought that the change he had made reflected a standard approach in the industry. Colin Todd considered that without any reference to specific examples of major capital works, it was too broad and was unusual.814 Todd {Day167/31:19-25}. Dr Lane considered it to be entirely incorrect.815 Lane {Day171/2:19}-{Day171/4:6}.
94¶39.33 The main problem created by the change was that it meant that in theory a responsible person could allow remedial measures to remain incomplete indefinitely, provided they had been started within the required time.816 Stokes {Day137/41:10-13}. In practice, however, Janice Wray understood the change to mean that in situations where it was not feasible to complete the work with the prescribed time, for example, because it was necessary to undertake a procurement exercise, the TMO needed to be able to demonstrate only that the necessary process had been put in hand.817 Wray {Day141/62:7-13}. She explained that the teams to which work was assigned did not see the schedule in its original form, because they received their instructions only after the action had been put onto the W2 system for completion.818 Wray {Day141/63:17-22}. In those circumstances we think that Carl Stokes's unusual and potentially dangerous approach to the completion of remedial work from 2014 onwards probably had little or no effect on how the TMO dealt with the work in practice.
The TMO's approach
¶39.34 Although Carl Stokes included priority ratings for the risks identified in his action plans, the TMO did not always accept them uncritically. On the contrary, on occasions, the management team even went so far as to challenge his professional judgement and seek to persuade him to change his findings. That was despite the fact that they had far less experience in matters of fire safety than he did. Other than Janice Wray, senior managers at the TMO were not experienced in matters relating to fire safety management and had not received training on it during their time at the TMO. Barbara Matthews, the director responsible for health and safety had no previous experience in that field and had received no fire safety training before or during her time at the TMO.819 Matthews {TMO10049987/1-2} pages 1-2, paragraphs 4 and 8; Matthews {Day147/103:15-20}; {Day147/100:6}-{Day147/102:23}. Similarly, Peter Maddison, the TMO's Director of Assets and Regeneration, had no qualifications or experience in the management of fire safety.820 Maddison {TMO00000892/14} page 14, paragraph 79. Although Robert Black had had some practical experience of health and safety, he had no relevant qualifications821 Black {Day149/7:4-17}. and had received no fire safety training.822 Black {Day149/7:18-20}.
Re-categorising actions – discussions between Janice Wray and Peter Maddison
¶39.35 On at least two occasions in 2014 and 2015, Peter Maddison and Janice Wray discussed the categorisation of deficiencies identified in fire risk assessments. The common factor in their discussions was his wish to divide the remedial measures into categories or sub-categories of priority actions.
The June 2014 intervention
¶39.36 The minutes of the TMO's Health and Safety Operational Meeting on 20 June 2014 record that during a discussion of statistics relating to fire risk assessments Peter Maddison asked Janice Wray which of the actions could be defined as absolute requirements and which were best practice.823 TMO Health and Safety Operational Meeting Minutes dated 20 June 2014 {TMO10009784/2}. Janice Wray's view was that there was nothing to clarify, other than the number of actions and which ones were "red", that is to say, urgent.824 Wray {Day141/141:17-21}. She was clear that she would not adjust the priorities but she said that she had not thought that Peter Maddison was seeking to treat some red items as having a slightly lower importance.825 Wray {Day141/142:16-19}; {Day141/142:20}-{Day141/143:3}. The upshot on that occasion was that she resisted his request. However, he did not give up.
95Peter Maddison's next request
¶39.37 The minutes of the TMO's Health and Safety Operational Meeting on 23 February 2015 record a discussion between Janice Wray and Peter Maddison in which he suggested that it would be useful to have more information about priority levels and the nature of each outstanding action.826 Health and Safety Operational Meeting Minutes dated 23 February 2015 {TMO00869479/1-2}. Janice Wray agreed to "split the outstanding actions into high, medium and low categories with targets".827 Health and Safety Operational Meeting Minutes dated 23 February 2015 {TMO00869479/2}.
¶39.38 Initially Peter Maddison told us that he had been seeking more information about what the different categories of action entailed.828 Maddison {Day122/206:1-3}. He said that his intention had been to get a better means of understanding what the actions were, the risk they presented and the urgency of remedying them.829 Maddison {Day122/206:4-15}. He thought that was the information he had asked for in June 2014 but had not received.830 Maddison {Day122/207:9-23}. However, he later conceded that by February 2015 his team did have access to spreadsheets setting out the actions and suggested that he was looking for a summary overview.831 Maddison {Day123/20:7-18}. We are not sure what Mr Maddison wanted and we are unable to place much reliance on his evidence of his intentions at the time, as it was rather confused. Janice Wray also thought that Peter Maddison, or members of his team, already had the information he wanted, but she nevertheless ran reports and produced high‑level information.832 Wray {Day141/146:18}-{Day141/147:4}.
¶39.39 It is unclear why Peter Maddison felt it necessary to ask Janice Wray for information his team already held. He was emphatic that he was not seeking to change the priorities assigned by Carl Stokes, but was seeking to address the backlog of actions as effectively as possible, although he accepted he might have been seeking to understand which of the high priority work was the most urgent.833 Maddison {Day123/24:24}-{Day 123/25:6}; {Day123/16:8-14}.
The Adair Tower fire risk assessment
¶39.40 The clearest example of the TMO's seeking to challenge Carl Stokes's risk assessments occurred after the fire at Adair Tower on 31 October 2015. Following that fire, Carl Stokes reviewed the fire risk assessment and action plan for Adair Tower which were discussed at a meeting between him and the TMO on 19 November 2015.834 Stokes {Day138/190:3-12}. The draft Record of Significant Findings and Action Plan included at item 12e a high priority recommendation that self-closing devices be fitted to all flat entrance doors that did not already have them.835 Record of Significant Findings and Action Plan for Adair Tower dated 11 November 2015 {CST00026368/3}. Carl Stokes told us that during that meeting he had advised the TMO to undertake the work set out in the action plan.836 Stokes {Day138/190:16-21}. His recollection of the meeting was that, although the TMO had suggested that there was no legal or regulatory requirement to fit self-closing devices, he had told it to fit them.837 Stokes {Day138/190:22-24}.
96¶39.41 The next day, 20 November 2015, Peter Maddison sent an email to Sacha Jevans, Janice Wray, Robert Black, Alex Bosman and Daniel Wood at 07:45 in which he questioned Carl Stokes's assignment of a high priority rating to the recommendation that self-closing devices be fitted.838 Correspondence between Janice Wray, Barbara Matthews, Peter Maddison, Sacha Jevans and Robert Black regarding revised FRA for Adair Tower dated 18-20 November 2015 {TMO00866493/3-4}. He explained that he did not consider that to be justified because it was not a statutory requirement to install self-closing devices retrospectively and because the entrance doors of the leasehold flats were demised to the leaseholders. The proposed action plan would therefore require the TMO to carry out work that it could not require the leaseholders to undertake.839 Correspondence between Janice Wray, Barbara Matthews, Peter Maddison, Sacha Jevans and Robert Black regarding revised FRA for Adair Tower dated 18-20 November 2015 {TMO00866493/4}. Peter Maddison could not remember how he had gained the understanding that there was no statutory requirement to fit self-closing devices.840 Maddison {Day123/135:16}-{Day123/136:17}. In his email he went on to express his concern that committing itself to carrying out work that it did not have the power to undertake would leave the TMO exposed. He suggested that the priority be reduced to "low" or "advice" and that a note be added that the TMO could not enforce the requirement in relation to leasehold properties.841 Correspondence between Janice Wray, Barbara Matthews, Peter Maddison, Sacha Jevans and Robert Black regarding revised FRA for Adair Tower dated 18-20 November 2015 {TMO00866493/4}. Peter Maddison was unable to explain exactly what he was concerned the TMO would be exposed to, other than possible criticism Maddison {Day123/134:9-13}.
¶39.42 Peter Maddison's view was supported by Barbara Matthews and Robert Black.842 Correspondence between Janice Wray, Barbara Matthews, Peter Maddison, Sacha Jevans and Robert Black regarding revised FRA for Adair Tower dated 18-20 November 2015 {TMO00866493/1-3}. In her response, Barbara Matthews said that Janice Wray had been instructed to raise the matter with Carl Stokes and that a revised Record of Significant Findings and Action Plan would be provided to the LFB.843 Correspondence between Janice Wray, Barbara Matthews, Peter Maddison, Sacha Jevans and Robert Black regarding revised FRA for Adair Tower dated 18-20 November 2015 {TMO00866493/3}. She later confirmed that Carl Stokes had changed his categorisation to "strong advice" (as he had), which, she said, had "no regulatory requirement or defined timescale" but was "advisory only".844 Correspondence between Janice Wray, Barbara Matthews, Peter Maddison, Sacha Jevans and Robert Black regarding revised FRA for Adair Tower dated 18-20 November 2015 {TMO00866493/1}.
¶39.43 It is surprising that Barbara Matthews supported Peter Maddison's view, given that she was aware that the LFB was keeping a close eye on this matter. Only a week before those email exchanges, Janice Wray had attended a meeting with Rebecca Burton to seek clarification on its response to the fire at Adair Tower.845 Correspondence between Janice Wray, Robert Black, Barbara Matthews, and Sacha Jevans, regarding Adair Tower meeting with LFB Fire Safety Team Leader dated 13 November 2015 {TMO00840415}. Following that meeting, she told Barbara Matthews that the LFB was focusing specifically on self-closing devices and smoke ventilation systems and that she thought the LFB might take a kinder view of smoke ventilation if the revised fire risk assessment recognised the need to fit self-closing devices and it was programmed to be completed swiftly.846 Correspondence between Janice Wray, Robert Black, Barbara Matthews, and Sacha Jevans, regarding Adair Tower meeting with LFB Fire Safety Team Leader dated 13 November 2015 {TMO00840415/2}. Barbara Matthews therefore decided to support Peter Maddison's suggestion that Carl Stokes be asked to downgrade the urgency of the action on self-closers despite knowing very well that the LFB was considering taking action against the TMO with a particular focus on self-closing devices on flat entrance doors.
97Carl Stokes's response to pressure from the TMO to amend his findings
¶39.44 Carl Stokes had not been included in the email conversation discussed in the previous section. On 20 November 2015, he sent an email to Janice Wray advising that the item in the action plan concerning fitting self-closing devices should continue to be rated high priority,847 Email correspondence between Carl Stokes, Barbara Matthews and Janice Wray regarding FRA for Adair Tower dated 20 November 2015 {CST00026445/2-3}. but agreed to alter that to "strong advice", partly to appease the LFB. However, he reiterated that the fitting of self-closing devices to the front doors of flats should be given a high priority.848 Email correspondence between Carl Stokes, Barbara Matthews and Janice Wray regarding FRA for Adair Tower dated 20 November 2015 {CST00026445/3}. As a result, that item was downgraded to "strong advice" and was not colour-coded.849 Record of Significant Findings and Action Plan for Adair Tower dated 11 November 2015 {CST00009046/5} item 12i.
¶39.45 When Carl Stokes was asked about his decision to alter the action plan, he said he felt able to make the change as the work was in hand.850 Stokes {Day138/200:17}-{Day138/201:9}. He also said that his reference to "appeasing" the LFB meant helping them, as it was better to be on the right side of the enforcing authority.851 Stokes {Day138/199:4-21}. Perhaps surprisingly, given his email of 20 November 2015 at 09.48, he said he thought it had been appropriate for the TMO to challenge his professional judgement and suggested that he had decided not to oppose it as the work was being undertaken in any event.852 Stokes {Day138/201:15-25}. However, when pressed he accepted that the change appeared to have been the result of pressure put on him by the TMO.853 Stokes {Day138/201:10-14}. That is exactly what had happened. The TMO, in full knowledge of risks involved, persuaded him to downgrade an important aspect of his assessment in relation to a building in which a serious fire had already occurred and in respect of which the LFB was already considering enforcement action.
¶39.46 Dr Lane and Mr Todd agreed that altering a recommendation in that way in response to pressure from a client was not consistent with the standards to be expected of a reasonably competent fire risk assessor854 Lane {Day171/9:21}-{Day 171/10:5}; Todd {Day167/40:17-24}. and we have no hesitation in saying that in doing so Mr Stokes was not acting professionally or in accordance with those standards.
¶39.47 We have analysed this episode at length not because it had any direct impact on what occurred at Grenfell Tower 20 months later but because it illuminates so well the TMO's general approach to fire safety. Its behaviour in seeking to challenge and dilute Mr Stokes's risk assessment, not for the first time, suggests that the TMO treated the demands of managing fire safety as an inconvenience rather than an essential aspect of its care for those living in the buildings under its management. It was a betrayal of its statutory obligations to its tenants.
98Remedial work
¶39.48 When she entered remedial work on the W2 system Janice Wray included a time for completion, which she took from the Record of Findings and Significant Actions. The time was treated as running from the date that she received the action plan and entered the work on the system.855 Wray {Day141/59:21-25}. She understood that the work was to be completed within the time indicated.856 Wray {Day141/60:1-3}. Janice Wray explained that she treated any work that had not been completed as "outstanding", not merely those items which had not been completed when the time allowed expired.857 Wray {Day141/86:4-17}. Over time, the number of outstanding items of work increased, but they were broadly unrelated to any particular kind of risk and do not appear to have been taken into account in assessing the overall risk affecting the TMO's properties.
¶39.49 From early 2012, various committees and groups within the TMO began to identify problems in dealing with the outstanding work. The minutes of a meeting of the TMO Health and Safety Committee on 26 January 2012 recorded that Janice Wray was continuing to chase up work arising from the assessments in relation to high-risk buildings carried out by Salvus in May 2010.858 TMO Health & Safety Committee Minutes dated 26 January 2012 {TMO10001026/3} item 8. By January 2012, therefore, the TMO was at least 12 months behind in completing some of the remedial work. Although Ms Wray was very concerned about the backlog and took steps to discover its cause,859 Wray {Day141/88:6-22}. she did not know what it was, other than that there were problems with contractors.860 Wray {Day141/91:3-8}
¶39.50 The arrears of remedial works were discussed at a meeting of the TMO Assets, Investment and Engineering Health and Safety Group on 15 March 2012. The minutes recorded that some work to put right some high – and medium-risk defects had been outstanding for as long as two years.861 TMO Assets, Investment and Engineering Health & Safety Group Minutes dated 15 March 2012 {TMO00869800/2} item 5.2. By December 2012 a significant amount of work was outstanding, which was causing concern.862 TMO Assets, Investment and Engineering Health & Safety Group Minutes dated 13 December 2012 {TMO10001903/3} item 6.2.
The Hodgson Report (July 2013)
¶39.51 In July 2013, Matt Hodgson produced the report on his review of the TMO's safety management to which we referred in Chapter 37.863 TMO Safety Management Review by Matt Hodgson dated 19 July 2013 {TMO10003124}. In a section of the report dealing with fire risk assessments he recorded that there were between 900 and 1,000 outstanding items of remedial work waiting to be completed.864 TMO Safety Management Review by Matt Hodgson dated 19 July 2013 {TMO10003124/33}. The figure is significant, first, because Matt Hodgson clearly thought it large enough to justify specific mention and secondly, because it is the earliest record of the amount of outstanding remedial work presented in that form to the TMO's executive team.
¶39.52 Although Mr Hodgson had drawn attention to the existence of that huge number of outstanding items of remedial work, Robert Black had little recollection of that part of the report and did not remember what he had done about it.865 Black {Day150/81:10-22}. He did not take any steps to find out why a backlog of that size had been allowed to accrue, because he regarded that as the responsibility of Anthony Parkes. He could not recall any discussions about it following the receipt of the report.866 Black {Day150/81:10-15}; Black {Day150/81:20-22}. As a result, there was no direction from the top and nothing to indicate that it was a serious problem that needed to be resolved urgently.
99¶39.53 Matt Hodgson's report was discussed by the TMO's executive team on 7 August 2013.867 TMO Executive Team Minutes dated 7 August 2013 {TMO00899807/1-2} item 1.4. The minutes of that meeting do not record a detailed discussion about the number of outstanding items of work as such, but do reflect concern that the Assets and Regeneration department was being bogged down with recommendations addressing the situation.868 TMO Executive team Minutes dated 7 August 2013 {TMO00899807/2} item 1.4. There is nothing to suggest that the number of outstanding items was regarded as a shocking statistic that demanded to be treated as an urgent priority.
¶39.54 Matt Hodgson produced a further report on 13 September 2013.869 TMO Safety Management Review by Matt Hodgson dated 13 September 2013 {TMO00873398} and Chapter 4A more generally. The reference to the number of remedial items outstanding had been removed from that version of the report, which instead referred only to the number of high priority items completed between 28 February and 17 July 2013.870 TMO Safety Management Review by Matt Hodgson dated 13 September 2013 {TMO00873398/31-32}. The arrears were now presented as a percentage of the total number of high priority items completed within a six-month period. It is unclear why that measure was chosen because, although the figures identified relatively low percentages of completions, for example, 34% by Assets and Regeneration Building Services and 34% by Response Repairs, the overall number of outstanding actions, and thus the scale of the backlog, was missing from the report.
¶39.55 Recommendation 16 of Mr Hodgson's report was to take steps to eliminate the backlog of remedial work.871 TMO Safety Management Review by Matt Hodgson dated 13 September 2013 {TMO00873398/12}, recommendation 16. Janice Wray was quite glad that he had made that recommendation, because she thought it would force the TMO to take the necessary action.872 Wray {Day141/118:24}-{Day141/119:3}. That was a telling admission because it suggested that her efforts to persuade the TMO's senior management to take the backlog seriously had thus far been in vain.
¶39.56 The final report also stated that the lack of sufficient information provided to the executive team relating to compliance with statutory duties had resulted in a want of leadership in making important changes or decisions needed to manage risk effectively.873 TMO Safety Management Review by Matt Hodgson dated 13 September 2013 {TMO00873398/8}. The completion of outstanding remedial work identified in fire risk assessments was given as a specific example.
¶39.57 In his original report Matt Hodgson had also referred to a breakdown in communication between the Health and Safety department and other departments in relation to remedial work.874 TMO Safety Management Review by Matt Hodgson dated 19 July 2013 {TMO10003124/8}. Janice Wray denied there had been a breakdown in communications, although she accepted that there had been some frustration,875 Wray {Day141/111:19}-{Day141/112:15}. but the fact is that Mr Hodgson's view was near enough the mark. It was on any view a clear warning that remedial work and the associated risks were not being effectively managed by the TMO and that one reason for that was structural.
100¶39.58 Between March 2012 and June 2017, the need to clear the arrears of remedial work was a constant topic of discussion by the Health and Safety Committee, but it did not consider detailed statistics until July 2015. Despite Matt Hodgson's reports in 2013 and the discussions in the various committees from 2012, the TMO was unable to keep up with the flow of remedial work. Janice Wray prepared a paper ("Paper 2") for a meeting of the TMO Health and Safety Committee on 31 July 2015 which showed the number of items of remedial work completed, partly completed and outstanding. Of the 1,850 items recorded, only 941, or about 50 percent, had been completed, leaving 909 outstanding or only partly completed.876 TMO Health & Safety Committee FRA Action Statistics Paper dated 31 July 2015 {TMO10009662/1}. That was similar to the position in July 2013 when Matt Hodgson produced his first report. At no time does the TMO Health and Safety Committee or the executive team appear to have considered the risk to life presented by the arrears.
¶39.59 Following the presentation of Janice Wray's paper in July 2015, Barbara Matthews, who had recently taken over executive responsibility for health and safety, asked her to produce a more informative breakdown of outstanding actions so that the committee could see the details better and understand what programme of work would be required to clear them.877 TMO Health & Safety Committee Minutes dated 31 July 2015 {TMO10010039/3} item 4.1. For the meeting on 29 September 2015, Janice Wray produced statistics which included a breakdown of work by priority for the contract management team and a breakdown of contract management work by category, showing how long they had been outstanding (by year).878 TMO Health & Safety Committee FRA Action Statistics Paper dated 28 September 2015 {TMO10010066/4-6}. A further paper including the breakdown of actions by priority and type was produced in November 2015.879 TMO Health & Safety Committee FRA Action Statistics Paper dated 23 November 2015 {TMO10011191}. However, when statistics were produced for the January 2016 meeting, far less detail was included (only two pages of the document related to fire risk assessment actions) and the paper no longer included information about the priority of actions, although an age profile was included.880 TMO Health & Safety Committee FRA Action Statistics Paper dated 9 January 2016 {TMO10011910}. Janice Wray was unable to explain why some of the detail had been removed, beyond saying that she thought she may have run out of time to prepare the document.881 Wray {Day141/171:14-18}. Subsequent papers containing statistics on remedial work did not provide the same level of detail as the papers produced in September and November 2015.882 See TMO Health & Safety Committee FRA Action Statistics Paper dated 6 April 2016 {TMO10012642}; TMO Health & Safety Committee FRA Action Statistics Paper dated 10 March 2017 {TMO10016217}.
¶39.60 Despite those efforts to monitor the number of items of remedial work and the progress in completing them, the TMO had not been able to bring the arrears under control by the time of the fire at Grenfell Tower. At the meeting of the TMO Health and Safety Committee on 19 January 2017, Barbara Matthews raised concern about the number of items of work that had been outstanding for more than 12 months. She required the various teams to whom the work had been assigned to explain their plans to complete it,883 TMO Health & Safety Committee Minutes dated 19 January 2017 {TMO10016020/2} paragraph 4.1. but explanations were provided by only two of the five teams.884 TMO Health & Safety Committee FRA Action Statistics Paper dated 16 March 2017 {TMO10016217/3}. Explanations received from Health & Safety Team and Neighbourhood Management South. Peter Maddison suggested that only teams with actions older than 12 months needed to provide a report, Maddison {Day123/98:14-17} however this was not Janice Wray's understanding, Wray {Day141/189:22}-{Day141/190:3}. The progress made following the meeting of the Health and Safety Committee in March 2017 was evidently insufficient and Barbara Matthews again expressed her concern at the number of outstanding actions at the next meeting of the committee on 13 June 2017, the day before the fire at Grenfell Tower.885 TMO Health & Safety Committee Minutes dated 13 June 2017 {TMO10021548/3} item 3.1.
101Interim measures: paragraph 14.4.2 of the fire safety strategy
¶39.61 The TMO's fire safety strategy made specific provision for instances where it was not possible to complete remedial work within the required time. Paragraph 14.4.2 provided that if high-priority work could not be completed within the time indicated, interim measures would be implemented to reduce the risk in the short term.886 TMO Fire Safety Strategy dated November 2013 {TMO00830598/10} paragraph 14.4.2. That was a sound attempt, in theory at least, to render the risk as low as reasonably practicable, but the TMO failed to create suitable plans to ensure that necessary interim measures were identified, documented or completed.887 PAS 79:2012 {CTA00000003/59} Clause 19 (ix); Lane, The Management and Maintenance of Grenfell Tower, Module 3 Report, Chapter 8 {BLARP20000027/141} paragraphs 8.2.37 - 8.2.39.
¶39.62 Janice Wray said that paragraph 14.4.2 had not been intended to apply in all cases in which remedial work had not been completed within the time allowed but only in those where significant delay was expected, such as where a lengthy procurement process was needed.888 Wray {Day141/75:6-10}; {Day141/76:5-10}. However, whenever it was thought that it might not be possible to complete high-priority remedial work within times indicated in the action plan, consideration should have been given to adopting interim measures, if appropriate.889 Wray {Day141/77:4-12}. In reality, however, that was only ever an aspiration. Although Ms Wray thought that over the years a number of interim measures had been implemented by the TMO,890 Wray {141/78:21-24}. she could not identify any, other than those relating to the smoke control system at Grenfell Tower.891 Wray {Day141/78:25}-{Day141/79:8}.
¶39.63 We have not been able to identify any occasion on which the TMO implemented interim measures. The TMO did not record such measures and although Janice Wray said that she would have put the details into the W2 system if she had known of them,892 Wray {Day141/79:13-16}. there was in fact no field in which information of that kind could be recorded. Although interim measures were said to have been recorded as an "update", there was no evidence from W2 of that having been done.893 Wray {Day141/79:17-24}. Indeed, Janice Wray admitted that there had been no system to record the fact that interim measures had been considered in relation to any particular high priority item or that a decision had been taken about it one way or the other.894 Wray {Day141/81:1-8}. She accepted that it would probably not be possible to find out whether in any particular case interim measures had been considered.895 Wray {Day141/80:16-19}. There was no formal system for notifying Carl Stokes of any decision to implement interim measures, although it is likely that Janice Wray discussed the matter with him first.896 Wray {Day141/81:15}-{Day141/82:7}.
Reporting on the progress of remedial measures
¶39.64 Remedial work was monitored by the TMO's Health and Safety Committee and also, before July 2015, by the TMO's Health and Safety Operational Committee.897 TMO Health & Safety Committee Meeting Minutes dated 31 July 2015 {TMO00880645/3} item 4.1. At the TMO Health and Safety Committee Meeting on 31 July 2015, Barbara Matthews is recorded in the minutes as stating that she hoped the committee would become the only Health and Safety Committee {TMO00880645/2} item 2.1. The minutes of the TMO's Health and Safety Committee were circulated for the consideration of the executive team.898 See the distribution list at the foot of the minutes of the TMO Health and Safety Committee {TMO00880645/8}.
102¶39.65 Janice Wray prepared reports on safety performance which were presented to the executive team and to TMO board meetings by members of the executive team.899 Wray {TMO00000890/37} page 37, paragraph 168. Anthony Parkes and his successor, Barbara Matthews, reported to the executive team and, to the best of Janice Wray's knowledge, presented her reports to the executive team.900 Wray {Day140/38:24}-{Day140/39:6}. During his evidence, Robert Black explained that the TMO's budget was not big enough to have someone with Health and Safety expertise on the executive team, Black {Day149/27:5-9}.
¶39.66 It appears that the TMO executive team never reported to the board on the need for remedial work or the extent of the delay in carrying it out. That is consistent with its failure to report to the board other matters of importance to fire safety. Barbara Matthews said that the only health and safety matters referred to the TMO board were those which had been included in the annual health and safety report or exceptional items, such as matters to do with the enforcement notice served following the fire at Adair Tower.901 Matthews {Day147/105:18}-{Day147/106:4}. As a result, the board lacked the information it needed to perform its function. It did not know whether the TMO was complying with its statutory duties and did not have the information it needed to make decisions that might enable its management to eradicate the arrears of remedial work.
¶39.67 The TMO's executive team itself does not appear to have been regularly and reliably provided with information about the arrears of remedial work, which, as was plain from the content of the minutes, was a chronic problem. If it had been given that information and had reported properly to the board, the board might have realised that the TMO had long-term difficulty completing remedial work.
Auditing the fire risk assessment programme
¶39.68 Although Janice Wray and the other members of the Health and Safety Committee gave frequent consideration to the question of remedial work, they never attempted to identify trends and failings in the delivery and implementation of the fire risk assessment programme. Such an audit was advised by clause 7.4 of PAS 7:2013.902 {LFB00116924/23} paragraphs 7.4.3 and 7.4.4. The failure to undertake such an exercise contributed to the TMO's lack of understanding of the underlying causes of the problem and its inability to overcome the arrears.
Resources
¶39.69 At many points in her evidence Janice Wray blamed a lack of money for her failure to act in a more efficient and effective way, but the evidence does not enable us to reach any firm conclusion on that question.
¶39.70 Robert Black was unsure whether the TMO had a specific budget or sub-budget line item for health and safety, and agreed that the TMO "probably" did not have a line item within the general budget to cover remedial work identified in fire risk assessments.903 Black {Day150/14:18}-{Day150/15:3}. However, he said that, if Barbara Matthews had asked for additional funds to eliminate the arrears of remedial work, he was sure that he would have been able to provide them, although he noted that as finance director she knew where all the money was.904 Black {Day150/120:2-10}.
103¶39.71 Barbara Matthews told us that there had been a specific budget to enable the TMO to meet its health and safety obligations. Although the budget was restricted,905 Matthews {Day147/144:2-12}. if there had been specific demands which could not be managed within the existing budget, it would have approached RBKC for additional funds.906 Matthews {Day147/144:13-24}. She could not recall any occasion on which RBKC had refused a request for additional funds.907 Matthews {Day147/144:25}-{Day147/145:9}. However, it had not occurred to her to approach RBKC to obtain funding for additional staff to support Janice Wray because she had felt that she might not have been able to make a strong enough case.908 Matthews {Day148/136:5-16}. She thus appears to have adopted a degree of self-restraint when considering whether to ask RBKC for more funds. By contrast, Janice Wray was under the impression that no additional funding was available.
¶39.72 It is difficult to tell why Janice Wray and Barbara Matthews had such divergent understandings of the position, given their shared responsibility to deliver the fire risk assessment programme. Throughout her evidence Janice Wray referred to many instances in the years 2009 until 2017 when she thought that the absence of funds was the reason why work had not been undertaken or why additional resources or assistance had not been sought. An early example of this was when she was asked about emergency plans and the recommendation by Salvus to ensure that all emergency plans were in accordance with government guidance.909 Salvus Fire Risk Assessment of TMO Fire Safety Policy and Procedures dated 22 September 2009 {SAL00000013/18} row 9.1. When asked why the TMO had not followed Salvus's advice, she said that she suspected that resources had not been available, but she could not recall asking for additional resources to enable her to do so.910 Wray {Day142/30:1-13}. It is interesting to note that neither the minutes of the TMO Health and Safety committee nor those of the regular meetings between the LFB and the TMO in those years contain any reference to difficulties caused by a lack of funds for fire safety matters. That suggests that lack of resources was not a real constraint, but in the end we do not consider that we have enough information about the TMO's finances or the extent to which RBKC was willing to make additional funds available to it to be able to reach a reliable conclusion on that question.
Failure to assess the risk posed by the arrears
¶39.73 None of Carl Stokes's fire risk assessments considered the risk posed to residents by the TMO's longstanding failure to carry out remedial work in a timely manner. As a result, he did not consider the extent to which the risk to the occupants of the building was enhanced by remedial measures not being carried out within the time required. Secondly, he failed properly to assess the effectiveness of the fire safety management system.
¶39.74 Clause 20.2 of PAS 79:2012 advised that when a fire risk assessment was reviewed, the assessor should confirm whether work previously recommended has been carried out911 PAS 79:2012 {CTA00000003/62} clause 20.2. and the template in Annex E relating to a review assessment included a section headed "Action on Previous Action Plan".912 PAS 79:2012 {CTA00000003/112}. It thus prompted the assessor to record whether remedial work required by the previous assessment had been carried out.
104¶39.75 Dr Lane considered that a fire risk assessor could not make a suitable and sufficient assessment of the risks affecting a building without identifying whether previous recommendations had been satisfactorily addressed,913 Lane {Day171/14:8-13}. and that a failure to include in a fire risk assessment information about whether previously identified remedial work had been carried out fell below the standard of a reasonably competent fire risk assessor.914 Lane {Day171/14:17}-{Day171/15:2}. Colin Todd agreed that it was important for a fire risk assessor to document in the assessment or action plan any items from previous assessments that had not been completed.915 Todd {Day167/41:20}-{Day167/42:9}. His preference was to identify deficiencies that had been found on the previous occasion and had not been rectified rather than simply treat them as new items,916 Todd {Day 167/42:6-10}. but he said approaches varied and a failure to deal with them in that way did not of itself fall below the standard to be expected of a reasonably competent fire risk assessor.917 Todd {Day167/43:4-23}. However, we are not sure why, given the standards set by PAS 79 and the self-evident risks arising from not keeping a track on the progress of previous fire risk assessments.
¶39.76 Carl Stokes's fire risk assessments and significant findings and action plans did not contain a section recording the completion or otherwise of recommendations made during a previous assessment. There is some evidence that during his inspections he looked at the previous Schedule of Significant Findings and Action Plan in order to see whether the TMO had complied with his recommendations, but even if he did so, it did not contribute to his overall assessment of the fire risk and he did not record his findings in the documents provided to the TMO. As a result, he could not tell how long individual deficiencies had remained outstanding. That was particularly important when assessing the extent to which the risk to residents was affected by arrears of remedial work.
¶39.77 However, Carl Stokes was aware that the TMO was not completing remedial work within the recommended times. a. In each of the Schedules of Significant Findings and Action Plans produced in 2010,
2012 and 2014, he asked for confirmation that the caretakers were checking and testing the installed fire protection systems and emergency lighting.918 Record of Significant Findings and Action Plan for Grenfell Tower dated 29 December 2010 {CST00003165/4-5} items 20, 23b & 23e; Record of Significant Findings and Action Plan for Grenfell Tower dated 20 November 2012 {CST00003083/5-6} items 23b & 23e; Record of Significant Findings and Action Plan for Grenfell Tower dated 17 October 2014 {CST00003177/9} items 23b & 23d. He said that he had been challenging the absence of a record of that work, but it must have been apparent to him by 2014 that, regardless of whether the checks and tests were in fact being carried out, the TMO had not established a proper system of keeping records over that 4-year period. Mr Stokes believed that he had taken that issue up with Janice Wray but was unable to recall the outcome.919 Stokes {Day136/210:18}-{Day136/211:10}.
¶b. On 13 November 2015, Alex Bosman sent Carl Stokes a consolidated spreadsheet containing a number of questions about recommendations that he wanted him to answer.920 Alex Bosman's FRA Queries Spreadsheet {CST00002213}. This document also contains entries where Alex Bosman asked Carl Stokes to "justify" the fire risk and classification of the action as "high risk" (Row 9). The spreadsheet contained recommendations relating to a range of buildings managed by the TMO drawn from assessments made in 2013, 2014, and 2015. They included recommendations classified as "high priority" which had been
105outstanding for 20 months.921 Alex Bosman's FRA Queries Spreadsheet {CST00002213}, see in particular Row 9. Mr Stokes responded a few days later attaching a revised spreadsheet containing his own annotations. It is clear from that document that by 16 November 2015 at the latest he had been aware that the TMO had been routinely and systematically failing to complete remedial work within the recommended times.922 Email from Carl Stokes to Janice Wray dated 16 November 2015 {CST00002482}; Annotated spreadsheet {CST00002483}.
¶c. In October 2016, Carl Stokes was instructed by Janice Wray to inspect Grenfell Tower before an audit scheduled to be undertaken by the LFB.923 Letter from Carl Stokes to Janice Wray dated 19 October 2016 {CST00003137}. The outcome of that inspection, as recorded in his letter of 19 October 2016, was that he found that 23 of the 46 recommendations he had made following the fire risk assessment on 20 June 2016, 43 of which had been described as being of "high priority", were still outstanding.924 Letter from Carl Stokes to Janice Wray dated 19 October 2016 {CST00003137}; Record of Significant Findings and Action Plan for Grenfell Tower dated 20 June 2016 {CST00003069}. Indeed, the majority of the recommendations in the June 2016 action plan were themselves outstanding from an earlier assessment made in April 2016.925 The Record of Significant Findings and Action Plan for Grenfell Tower dated 26 April 2016 {CST00003098} contained 42 entries; Record of Significant Findings and Action Plan for Grenfell Tower dated 20 June 2016 {CST00003069} contained 46 entries of which 31 were identical or in close terms to a corresponding entry from the April 2016 document. Further, 14 of the recommendations described by Carl Stokes in his letter of 19 October 2016 as outstanding appear in both the April and October 2016 action plans and were unresolved, despite having been brought to the TMO's attention six months earlier.
¶39.78 Accordingly, by October 2016 at the latest, Carl Stokes was aware that the TMO was not carrying out remedial work promptly. He expressed his frustration with the failure to complete work that ought to have been carried out within two or three weeks.926 Stokes {Day138/139:25}-{Day138/140:6}. He suggested that he had contacted Janice Wray to ask her why the work had not been undertaken but he could not remember what her response had been.927 Stokes {Day138/140:18-25}. He did not record his advice and there is no other evidence to show that he gave it.
107