Grenfell Tower Inquiry: Phase 2 Report · 2024
Chapter 43: The smoke ventilation system
Chapter 43: The smoke ventilation system
The system
¶43.1 Grenfell Tower was equipped with a ventilation system designed to allow the passage of air through the building for ventilation and the extraction of smoke in the event of a fire. Ventilation depended entirely on natural airflow. The extraction of smoke depended on the natural convection of hot smoke but could be boosted by mechanical means. The booster fans were designed to be operated manually by the fire and rescue service.
¶43.2 The system comprised two pairs of shafts running the full height of the building with openings into each lift lobby controlled by louvred dampers. In the event of a fire the dampers were designed to open on the floor affected by the fire and close on all other floors, thereby allowing smoke to flow up the shaft to the opening at roof level without escaping into lobbies on other floors.
The fire at Grenfell Tower on 30 April 2010
¶43.3 On 30 April 2010, a fire was started deliberately outside Flat 64 at Grenfell Tower.1304 Wray {TMO00000890/43} page 43, paragraphs 195-196; LFB notifiable fire report into the fire {LFB00000201/1-2}; LFB report into the fire dated 22 December 2010 {IWS00001463/3}. During the fire, the smoke ventilation system (sometimes referred to as the automatic opening vent system or AOV) failed to operate properly.1305 Wray {TMO00000890/43} page 43, paragraphs 195-196; LFB notifiable fire report into the fire {LFB00000201/2}; LFB report into the fire dated 22 December 2010 {IWS00001463/3}. Smoke leaked into the lobbies of eight other floors, which led a number of residents to believe they were trapped and call the LFB.1306 Email from Janice Wray to Collette O'Hara on 5 May 2010 {TMO10048221/4} item 2; TMO spreadsheet of previous fires {TMO00873387} "fires" sheet, row 6; LFB notifiable fire report into the fire {LFB00000201/1-2}; LFB report into the fire dated 22 December 2010 {IWS00001463/3}.
¶43.4 On 5 May 2010, Janice Wray sent the results of her investigation into the fire to Collette O'Hara, an LFB fire safety inspecting officer.1307 Email from Janice Wray to Collette O'Hara on 5 May 2010 {TMO10048221/4-5}. She explained that the system was subject to quarterly inspections by RGE Services (RGE)1308 Email from Janice Wray to Collette O'Hara on 5 May 2010 {TMO10048221/4} item 3. and said that the most recent inspection had identified "incomplete sealing" of a number of dampers.1309 Email from Janice Wray to Collette O'Hara on 5 May 2010 {TMO10048221/4} item 3. She said that the remedial work had been delayed and had therefore not been carried out by the time of the fire.1310 Email from Janice Wray to Collette O'Hara on 5 May 2010 {TMO10048221/4} item 3. Janice Wray accepted, in retrospect, that the TMO should have implemented interim measures while the system was being repaired.1311 Email from Janice Wray to Collette O'Hara on 5 May 2010 {TMO10048221/4-5} items 3-4; TMO spreadsheet of previous fires {TMO00873387} "fires" sheet, row 6.
¶43.5 When he replied to Janice Wray on 6 May 2010,1312 Email from Spencer Sutcliff to Janice Wray on 6 May 2010 {TMO10048221/2}. Spencer Sutcliff, the leader of the LFB Fire Safety team, agreed that the TMO should implement interim measures in future.1313 Email from Spencer Sutcliff to Janice Wray on 6 May 2010 {TMO10048221/2}. He also recommended that the TMO introduce a procedure to assess faults in fire safety systems to ensure that any high-priority remedial work was completed to a strict time scale.1314 Email from Spencer Sutcliff to Janice Wray on 6 May 2010 {TMO10048221/2}. He expressed surprise about the amount of smoke leakage caused by defective sealing of the vents1315 Email from Spencer Sutcliff to Janice Wray on 6 May 2010 {TMO10048221/3}. and recommended that the entire system be tested by an engineer because of what he described as a "catastrophic failure of the system".1316 Email from Spencer Sutcliff to Janice Wray on 6 May 2010 {TMO10048221/3}.
148¶43.6 Janice Wray replied to Spencer Sutcliff on 12 May 2010.1317 Email from Janice Wray to Spencer Sutcliff on 12 May 2010 {TMO10048221/1}. She included an earlier response from the TMO's senior electrical engineer, Keith Fifield,1318 Email from Keith Fifield to Janice Wray on 6 May 2010 {TMO10048217/1}. who had explained that the remedial work, which had been agreed before the fire, included a complete overhaul of the system1319 Email from Keith Fifield to Janice Wray on 6 May 2010 {TMO10048217/1}. and that, when the work had been done, the system would be fully operational.1320 Email from Keith Fifield to Janice Wray on 6 May 2010 {TMO10048217/1}. Mr Fifield did not agree that the failure had been catastrophic.1321 Email from Keith Fifield to Janice Wray on 6 May 2010 {TMO10048217/1}. He said that, except for the incomplete sealing, the system was working properly, but that there had been a failure to activate the mechanical extract system manually during the fire.1322 Email from Keith Fifield to Janice Wray on 6 May 2010 {TMO10048217/1}. He said that he had arranged for smoke tests to be carried out on completion of the work.1323 Email from Keith Fifield to Janice Wray on 6 May 2010 {TMO10048217/1}.
¶43.7 On 7 May 2010, Janice Wray told Spencer Sutcliff that the remedial work had been completed and a smoke test had been successfully undertaken.1324 Email from Janice Wray to Spencer Sutcliff on 12 May 2010 {TMO10048221/1}.
RGE's inspections of the system 2009 – 2010
¶43.8 On 28 July 2009, the TMO appointed RGE to carry out maintenance work on the fire safety equipment and systems.1325 Letter from Keith Fifield to RGE dated 28 July 2009 {RGE00000003}. At some time after, but before the fire at Grenfell Tower on 30 April 2010, RGE had carried out its first test on the system.1326 Undated RGE maintenance report on AOV system at Grenfell Tower {MAX00001414/3}. There is an undated maintenance report that refers to fire damage, suggesting that it was completed after the fire on 30 April 2010,1327 Undated RGE maintenance report on AOV system at Grenfell Tower {MAX00001414/5}. but it also refers to a "first visit" to test the system, which RGE apparently carried out before the fire. In that report RGE said that all fresh air inlet dampers were in the open position and had been for some years. As a result, most of them were seized open or so contaminated that they were impossible to close and reset.1328 Undated RGE maintenance report on AOV system at Grenfell Tower {MAX00001414/5}.
¶43.9 If the dampers were open and unable to close, smoke could spread between lobbies through the system in the event of a fire.1329 As explained by Dr Lane in her Module 3 report, The Management and Maintenance of Grenfell Tower – Chapter 7 {BLARP20000033/355} paragraph 15.4.14. It is a matter of concern that the situation had apparently existed for a number of years before RGE's inspection. Although it is not clear precisely when that first visit took place, there are records of RGE having been instructed to carry out repairs on the system on 4 January 2010 and 20 April 2010, so it was probably before then.1330 Capita Repair Spreadsheet {RBK00053524} row 4870 and row 4701; Repair order raised with RGE on 20 April 2010 {RBK00046981}. A quotation from RGE dated 20 April 2010 refers to stripping down, cleaning and lubricating each vent, which, on the face of it, relates to the problems identified during the "first visit".1331 Quote from RGE for £2,257.05 to carry out repair work to the system at Grenfell Tower {RBK00013641}. They appear to have been the repairs Janice Wray had referred to in her emails to the LFB fire safety team following the fire at Grenfell Tower on 30 April 2010, which she said had been completed on 7 May 2010.1332 Email from Janice Wray to Collette O'Hara on 5 May 2010 {TMO10048221/4} item 3; Email from Janice Wray to Spencer Sutcliff on 12 May 2010 {TMO10048221/1}.
149¶43.10 RGE produced another maintenance report dated 12 May 2010 that set out the results of its tests on the system after the fire on 30 April 2010.1333 RGE maintenance report on smoke ventilation system at Grenfell Tower dated 12 May 2010 {RBK00013637}. It concluded that due to the spring force on the inlet dampers the actuators were not reliable and might not operate on every activation, but that the system was otherwise generally in good operational order and capable of being maintained for the next 5 years.1334 RGE maintenance report on smoke ventilation system at Grenfell Tower dated 12 May 2010 {RBK00013637/7}. The report included a quotation of £27,280 for work to the inlet dampers to ensure that they automatically opened and closed without manual intervention.1335 RGE maintenance report on smoke ventilation system at Grenfell Tower dated 12 May 2010 {RBK00013637/8}.
¶43.11 Janice Wray said that she had not been made aware of that report, either before she replied to Spencer Sutcliff on 12 May 2010 or after.1336 Wray {Day144/22:14-21}. She said that the TMO's Contract Management team dealt with RGE,1337 Wray {Day144/23:2-20}. but that she would have expected Keith Fifield to provide the report to her.1338 Wray {Day144/24:1-13}. We have not seen any evidence that the remedial work identified by RGE in its report dated 12 May 2010 was ever carried out.1339 There is, for example, no record of a repair corresponding with this quote in the Capita Repair Spreadsheet, whereas there are records of the repairs raised on 4 January 2010 and 20 April 2010 {RBK00053524}.
¶43.12 An RGE engineer carried out a further test on the smoke ventilation system at Grenfell Tower on 4 June 2010.1340 RGE service/maintenance sheet for smoke test to smoke ventilation system at Grenfell Tower dated 4 June 2010 {RBK00046980}. The service sheet says that the purpose was to test the fire dampers following the recent fire and remedial works.1341 RGE service/maintenance sheet for smoke test to AOV system at Grenfell Tower dated 4 June 2010 {RBK00046980}. It is likely that the sheet refers to the remedial works for which instructions were given on 20 April 2010 and which were completed on 7 May 2010, given that there is no evidence that the remedial works identified in the report dated 12 May 2010 were carried out. Despite that, the engineer stated that following the test he had left the site in full working order as witnessed by Keith Fifield and others.1342 RGE service/maintenance sheet for smoke test to smoke ventilation system at Grenfell Tower dated 4 June 2010 {RBK00046980}; Email from Janice Wray to Collette O'Hara on 7 June 2010 about the smoke test {LFB00000767}.
¶43.13 In about August 2010, the TMO started to consider the need to modernise or replace the smoke ventilation system at Grenfell Tower.1343 Minutes of the Asset Investment and Engineering Health and Safety Group meeting on 26 August 2010 {TMO10000725/3} item 2. The minutes of the meeting of the Asset Investment and Engineering Health and Safety Group on 26 August 2010 recorded that the feasibility of modernising the smoke extraction system was being examined.1344 Minutes of the Asset Investment and Engineering Health and Safety Group meeting on 26 August 2010 {TMO10000725/3} item 2. Janice Wray suggested that the need for that had been brought to the TMO's attention by the fire on 30 April 2010, which had brought to light the age of the system, rather than by RGE's report in May 2010 or the failure of the system to operate properly.1345 Wray {Day144/26:23}-{Day144/27:11}.
150The Leaseholders' Association's complaint
¶43.14 In July 2010, the Grenfell Tower Leaseholders' Association made a complaint about fire safety which included a specific concern about the operation of the smoke ventilation system. The evidence suggests that the TMO was less than full and frank in its response. In particular, it did not tell the leaseholders or other residents of the tower about the defects in the system which had been found by RGE or the heightened risk to their safety.
¶43.15 On 28 July 2010, the Leaseholders' Association wrote to Geoff Payne, the TMO's Head of Housing, making various complaints including a complaint that during the fire on 30 April 2010 smoke had entered lobbies on other floors of the tower.1346 Letter from GTLA to Geoff Payne on 28 July 2010 {IWS00001497/2}. It asked what defects had been found in the system and what action had been taken in response.1347 Letter from GTLA to Geoff Payne on 28 July 2010 {IWS00001497/2}. Daniel Wood, the TMO's Head of Home Ownership, responded on 20 August 2010,1348 Letter from Daniel Wood to GTLA on 20 August 2010 {TMO00846311}. saying that there had been a "minor fault" in the system that had been identified during the service visit before the fire.1349 Letter from Daniel Wood to GTLA on 20 August 2010 {TMO00846311/4}. He said that repairs had been put in hand and that, when completed, the system would be fully operational.1350 Letter from Daniel Wood to GTLA on 20 August 2010 {TMO00846311/4}. He said that the problem with leaking vents had been put right.1351 Letter from Daniel Wood to GTLA on 20 August 2010 {TMO00846311/4}.
¶43.16 On 3 September 2010, the Leaseholders' Association wrote to Robert Black about their complaints.1352 Letter from GTLA to Robert Black on 30 September 2010 {TMO10037439}. Among other matters it asserted that the recent fire had raised so many health and safety questions that it demanded an independent investigation into the safety of the building.1353 Letter from GTLA to Robert Black on 30 September 2010 {TMO10037439/2}. Later, when dealing with the fire, it said that if the smoke ventilation system was not working it should be considered a major rather than a minor fault as Mr Wood had described it.1354 Letter from GTLA to Robert Black on 30 September 2010 {TMO10037439/5}.
¶43.17 Anthony Parkes replied on 21 September 2010.1355 Letter from Anthony Parkes to GTLA dated 21 September 2010 {TMO00846320}. He acknowledged that the seals on some of the vents had leaked, but said that otherwise they had been working at the time of the fire.1356 Letter from Anthony Parkes to GTLA dated 21 September 2010 {TMO00846320/4}. He said that the effects of the fire would not have been so serious if the LFB fire fighters had activated the smoke extract fan manually, but that they had not known how to do so.1357 Letter from Anthony Parkes to GTLA dated 21 September 2010 {TMO00846320/4}. He also said that the system was being upgraded so that it would work automatically when the fire alarm sounded.1358 Letter from Anthony Parkes to GTLA dated 21 September 2010 {TMO00846320/4}. Mr Parkes gave an assurance that the system was regularly checked and test reports completed.1359 Letter from Anthony Parkes to GTLA dated 21 September 2010 {TMO00846320/4}.
¶43.18 Neither Daniel Wood nor Anthony Parkes referred to RGE's report of 12 May 2010, which had advised that the inlet dampers might not operate on every activation and recommended significant remedial work.1360 RGE maintenance report on smoke ventilation system at Grenfell Tower dated 12 May 2010 {RBK00013637/7-8}. As set out above, we have seen no evidence that that remedial work was carried out.
151RGE's inspection of the system in 2011
¶43.19 On 9 August 2011, RGE produced a further test report on the system at Grenfell Tower.1361 RGE maintenance report on smoke ventilation system at Grenfell Tower dated 9 August 2011 {TMO00894311}. In section 3, under the heading "Test Results / Urgent Recommendation", it said that, having maintained the system for over 12 months, it could not guarantee that it would operate as required or that it met the requirements of the fire regulations. In particular, it reported that the systems for actuating the vents in the lobbies were no longer reliable and were found to have opened at random between maintenance visits. They were no longer fit for purpose and needed to be replaced.1362 RGE maintenance report on smoke ventilation system at Grenfell Tower dated 9 August 2011 {TMO00894311/5}.
¶43.20 Janice Wray said that she had not been made aware of that report either.1363 Wray {Day144/25:3-11}. Keith Fifield, however, was certainly aware of it. He discussed it at a meeting with RGE on 7 September 2011.1364 Minutes of RGE Contract Review meeting with the TMO on 7 September 2011 {TMO00848054/1} item 1.7. The minutes of that meeting record that he had seen the report and was aware that RGE could not guarantee that the system would work in the event of an emergency.1365 Minutes of RGE Contract Review meeting with the TMO on 7 September 2011 {TMO00848054/1} item 1.7. They also recorded that he had said that the matter was being looked into by the TMO and that RGE and other contractors would be invited to submit tenders for the necessary work.1366 Minutes of RGE Contract Review meeting with the TMO on 7 September 2011 {TMO00848054/1} item 1.7.
¶43.21 The required improvements to the system at Grenfell Tower were discussed at a meeting of the TMO Asset Investment and Engineering Health and Safety Group on 15 September 2011 attended by Keith Fifield and Janice Wray.1367 Minutes of Asset Investment and Engineering Health and Safety Group meeting on 15 September 2011 {TMO00869798/1-2} item 2.2(e). The minutes of the discussion do not refer to RGE's recent report,1368 Minutes of Asset Investment and Engineering Health and Safety Group meeting on 15 September 2011 {TMO00869798/1-2} item 2.2(e). but in our view, given Keith Fifield's knowledge of that report, it is unlikely that the modernisation or replacement of the system was discussed without mentioning the significant findings it contained.
¶43.22 Despite the reports made by RGE in May 2010 and August 2011, we have seen no evidence that the TMO gave any consideration at that time to implementing measures to mitigate the risk presented by the potential failure of the smoke ventilation system to operate in the event of a fire. That was despite the assurance Janice Wray had given the LFB Fire Safety team after the fire on 30 April 2010 that it would do so.1369 Email from Janice Wray to Collette O'Hara on 5 May 2010 {TMO10048221/4-5}.
Modernisation of the system
¶43.23 Even if Janice Wray was not aware of the findings made by RGE in August 2011, it is reasonably clear that she was aware of at least some of the concerns about the system that had been identified in the course of the feasibility study for its modernisation.
¶43.24 In October 2011, AECOM, a construction industry consultancy, produced a tender for the modernisation of the system.1370 AECOM tender for upgrade to fire alarm and smoke extract system dated October 2011 {MAX00017497}. In a description of the existing system it noted that some of the dampers leaked, making it possible for smoke from a fire on a lower floor to leak through the closed dampers on an upper floor into the lift lobby. It was also possible that more than one set of dampers would open at any one time, since there was no way of establishing whether dampers were open other than by visual inspection. Although the extractor fans would overcome those problems, they had to be started manually by the fire brigade.1371 AECOM tender for upgrade to fire alarm and smoke extract system dated October 2011 {MAX00017497/6-7}.
152¶43.25 Apart from the installation of an autodialler to monitor the system remotely when staff were not on site, we have seen no evidence that Janice Wray or anyone else at the TMO considered measures to mitigate the risk caused by the defects in the system pending its modernisation. Further, although the tender document was produced in October 2011, no work had been carried out by late 2013 when it was included in the refurbishment, and it was not completed until April 2016, some four and a half years later.1372 See, for example, email from Bruce Sounes to John Allen and Paul Hanson (RBKC Building Control) copying in Terry Ashton and Duncan Campbell on 23 October 2013 {TMO10040556}. It was commissioned in April 2016: PSB Above Ground Commissioning Report dated 28 April 2016 {PSB00000224/7}. Janice Wray told us that the work had been put back so that it could form part of the refurbishment.1373 Wray {Day144/46:14}-{Day144/47:4}.
The fire risk assessments 2009-2012
¶43.26 Having heard the evidence of Dr Lane and Mr Todd, we are satisfied that a fire risk assessor should assess the risk that the means of escape might be compromised by a failure of a smoke ventilation system to work.1374 Todd {Day168/24:18-22}; Lane {Day172/3:4-11}. He could not reasonably be expected to test the system, but should satisfy himself that the system had been effectively tested and maintained in efficient working order, either by checking the records or by making reasonable enquiries of the competent person.1375 Todd {Day168/24:14}-{Day168/26:14}; {Day172/3:12}-{Day172/4:5}; {Day172/5:4}-{Day172/6:17}; Lane Module 3 Report, The Management and Maintenance of Grenfell Tower, Chapter 8 {BLARP20000027/267} s.12.3.14-15. If the necessary information is not immediately available, the fire risk assessor should make a further effort to acquire it.1376 Todd {Day168/26:16}-{Day168/27:10}; Lane {Day172/14:14}-{Day172/15:7}; {Day172/15:15}-{Day172/16:1}. There may be occasions when a fire risk assessor might ask to see the equipment tested,1377 Lane {Day172/6:25}-{Day172/7:20}. but that would not be normal.1378 Todd {Day168/26:12-14}. In the absence of satisfactory information about testing and maintenance he should increase the assessment of risk until provided with information to justify reducing it.1379 Lane {Day172/15:8}-{Day172/16:1}. We agree that the absence of available information about the testing and maintenance of a system of that kind indicates a shortcoming in the responsible person's management of fire safety in relation to the building in question.1380 Todd {Day168/29:1-7}; Lane {Day172/16:2}-{Day172/17:1}.
PAS 79:2012
¶43.27 The approach of Dr Lane and Colin Todd was, in essence, the same as that set out in PAS 79:2007 and PAS 79:2012.1381 PAS 79:2007 {CTA00000001}; PAS 79:2012 {CTA00000003}. The guidance in relation to smoke ventilation systems is materially the same in the two versions. Clause 15 of PAS 79:2012, entitled "Assessment of Fire Protection Measures", states that among the systems that should be taken into account are smoke control systems, which, in some premises can be essential for the protection of the means of escape. It is often vital to ensure that there are adequate arrangements for control, testing and maintenance of such systems.1382 PAS 79:2012 {CTA00000003/45-48}; See Clause 14 in PAS 79:2007 for the equivalent paragraphs {CTA00000001/42-45}.
153¶43.28 Clause 16 says that fire safety management, which includes the testing and maintenance of fire protection systems, and fire protection measures should be regarded as of equal importance.1383 PAS 79:2012 {CTA00000003/50-53}; See Clause 15 in PAS 79:2007 for the equivalent paragraphs {CTA00000001/46-47}.
The approach of Carl Stokes
¶43.29 Carl Stokes told us that he never tested or witnessed the testing of the smoke ventilation system at Grenfell Tower during his fire risk assessments.1384 Stokes {Day139/4:14-17}. He said that in order reliably to verify that the system was functioning correctly he used the contractor's service sheets and made certain that he had one that was in date.1385 Stokes {Day139/4:18-21}. He preferred to use that information rather than ask Janice Wray about the condition and operation of the system, because she would have had to go to the same source material.1386 Stokes {Day139/4:22}-{Day139/5:12}.
The fire risk assessment in September 2009
¶43.30 In the fire risk assessment of Grenfell Tower he carried out on behalf of Salvus in September 2009, Carl Stokes reported that he could not confirm that the smoke ventilation system had been maintained and tested in accordance with current guidance and British Standards.1387 Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/14}. He advised that that presented a medium to high risk and recommended that the TMO confirm within a month whether the system had been tested and, if not, that it engage a competent engineer to do so within three months.1388 Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/18} item 9.2.
¶43.31 The action plan based on that assessment, which was revised by the TMO in October 2009, stated that regular maintenance was being carried out.1389 Fire Risk Assessment Action Plan for Grenfell Tower updated in October 2009 {CST00000019} rows 52-54. It is not clear precisely when RGE carried out its first test of the system.1390 Undated RGE maintenance report on AOV system at Grenfell Tower {MAX00001414/5}. If it had taken place by the time of Carl Stokes's fire risk assessment, it is not clear why the test results, which had identified defects in the dampers which had existed for possibly five years, were not provided to him or why he was otherwise unable to obtain them.1391 Undated RGE maintenance report on AOV system at Grenfell Tower {MAX00001414/5}.
The fire risk assessment in December 2010
¶43.32 Carl Stokes completed his next fire risk assessment of Grenfell Tower on 29 December 2010.1392 Fire Risk Assessment for Grenfell Tower dated 29 December 2010 {CST00003181}. In it he referred to the fire on 30 April 2010 (although he incorrectly dated it as July 2010), but he did not mention that the system had not operated as intended.1393 Fire Risk Assessment for Grenfell Tower dated 29 December 2010 {CST00003181/5}. He told us that he had not been aware that there had been a leakage of smoke during the fire.1394 Stokes {Day139/7:3-9}. He said he would have expected Janice Wray to give him that kind of information or for it to be included in the service reports for the system.1395 Stokes {Day139/7:3-13}. Janice Wray, for her part, could not remember having given him that information.1396 Wray {Day144/7:1-21}; {Day144/9:11-21}.
154¶43.33 In the Record of Significant Findings and Action Plan dated 29 December 2010, Mr Stokes noted that there were automatic opening vents in each lobby area, but that he did not know whether the system had been serviced and maintained.1397 Record of Significant Findings and Action Plan for Grenfell Tower dated 29 December 2010 {CST00003165/5} item 23c. He sought confirmation of that as a matter of high priority.1398 Record of Significant Findings and Action Plan for Grenfell Tower dated 29 December 2010 {CST00003165/5} item 23c. That essentially repeated the request he had made in the fire risk assessment carried out in 2009.1399 Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/18} item 9.2. However, we have seen no evidence either that he sought, or that the TMO provided, the confirmation he had asked for before he completed the assessment. Carl Stokes could not remember whether he had asked for it.1400 Stokes {Day139/11:15-19}.
¶43.34 The failure to obtain that information as part of the fire risk assessment was significant because, by that stage, RGE had identified defects in the inlet dampers in their maintenance report dated 12 May 2010 and the TMO had begun to consider the need to modernise or replace the system.1401 RGE maintenance report for the smoke ventilation system at Grenfell Tower dated 12 May 2010 {RBK00013637/7}; Minutes of the Asset Investment and Engineering Health and Safety Group meeting on 26 August 2010 {TMO10000725/3} item 2. Carl Stokes said that he had not been aware of RGE's concerns about the inlet dampers,1402 Stokes {Day139/8:1-15}. and as he did not have that information, he could not take it into account when making his assessment of the risk at Grenfell Tower. Nor could he advise on the need for measures to mitigate the risk presented by the defects in the system pending its renovation or improvement.
The fire risk assessment in November 2012
¶43.35 Carl Stokes completed his next fire risk assessment of Grenfell Tower on 20 November 2012.1403 Fire Risk Assessment of Grenfell Tower dated 20 November 2012 {CST00003084}. In section 23, he ticked the box to indicate that there was no record of monthly testing or annual servicing of the smoke ventilation system1404 Fire Risk Assessment of Grenfell Tower dated 20 November 2012 {CST00003084/28}. but did not provide any comment or observation.1405 Colin Todd explained that, where "no" was ticked in the fire risk assessment to a proforma question, the fire risk assessor should include commentary explaining the "no" in the fire risk assessment, then there should be a corresponding action in the action plan: Todd {Day168/34:5}-{Day168/36:3}. In his Record of Significant Findings and Action Plan, he referred to the presence of automatic opening vents in each lobby and asked for confirmation that they were serviced and maintained. He rated that a matter of high priority.1406 Record of Significant Findings and Action Plan dated 20 November 2012 {CST00003083/5} item 23c.
¶43.36 That was the third time that Mr Stokes had said that he did not know whether the system had been routinely tested and maintained, but we have seen no evidence that he tried to obtain the maintenance records before he completed his assessments.1407 Carl Stokes said it would have been covered in meetings with Janice Wray, but the Inquiry has seen no evidence in support of that assertion, Stokes {Day139/16:1-12}. Moreover, he made no comment about what had become a persistent and, in our view, worrying problem. Nor did he vary his assessment of the fire risk at Grenfell Tower, which he considered "tolerable", to account for the possibility that the system might not have been maintained in efficient working order.1408 Carl Stokes's Fire Risk Assessment of Grenfell Tower dated 20 November 2012 {CST00003084/10}.
155¶43.37 Carl Stokes's failure to request that information before he completed his assessment, and the TMO's failure to provide it, was especially significant in November 2012. By that stage, RGE had stated in explicit terms in its report dated 9 August 2011 that it could not guarantee that the system would work.1409 RGE maintenance report on the smoke ventilation system at Grenfell Tower dated 9 August 2011 {TMO00894311/5}. The AECOM tender of 19 October 2011 also referred to serious defects in the system.1410 AECOM tender for upgrade to fire alarm and smoke extract system dated October 2011 {MAX00017497/6-7}. That information should have been taken into account in assessing the risk and measures should have been put in place to mitigate it, pending the completion of remedial work. However, Mr Stokes did no more than renew his request for confirmation that the system had been tested and maintained.
The Leaseholders' Association's complaints in 2012
¶43.38 On 14 November 2012, the Leaseholders' Association wrote a further letter to David Ward about the concerns felt by its members about being excluded from the programme to replace flat entrance doors in 2011 to 2012.1411 Letter/email from GTLA to David Ward on 18 November 2012 {TMO00842270}. It complained that leaseholders had not been told after the fire on 30 April 2010 that their entrance doors might not comply with safety regulations and questioned whether other health and safety equipment was in working condition and fit for its purpose.1412 Letter/email from GTLA to David Ward on 18 November 2012 {TMO00842270/2}. It therefore asked for copies of all reports, conclusions or recommendations relating to any investigation into the fire.1413 Letter/email from GTLA to David Ward on 18 November 2012 {TMO00842270/2}.
¶43.39 On 22 November 2012, in preparing a response to that complaint, Janice Wray sent an email to Paul Dunkerton containing information about the fire on 30 April 2010.1414 Email from Janice Wray to Paul Dunkerton on 22 November 2012 {TMO00848792}. She said it would be inappropriate to provide the leaseholders with a copy of the email she had sent to the LFB Fire Safety team after the fire.1415 Email from Janice Wray to Paul Dunkerton on 22 November 2012 {TMO00848792}. Instead, she proposed telling them that the smoke ventilation system had removed the smoke from the lift lobby, but had not worked as effectively as it should have because of a need for remedial works that were then pending. All those works had been completed and the system continued to operate effectively.1416 Email from Janice Wray to Paul Dunkerton on 22 November 2012 {TMO00848792}.
¶43.40 Paul Dunkerton included that information in his reply to the Leaseholders' Association on 14 December 2012.1417 Letter from Paul Dunkerton to Tunde Awoderu, GTLA, on 14 December 2012 {TMOH00027328/2}. By that time, however, the TMO had for a long time been in possession of RGE's report dated 9 August 2011, which stated explicitly that it could not guarantee that the system would work, and AECOM's tender, which described its defects.1418 AECOM tender for upgrade to fire alarm and smoke extract system dated October 2011 {MAX00017497/6-7}. Even if Janice Wray had not seen those documents, she should have asked Keith Fifield for information about the maintenance of the system before responding to Paul Dunkerton.1419 Wray {Day144/36:1-7}; {Day144/39:15-18}. There is no evidence that she did so.
¶43.41 By omitting that information from its reply, the TMO failed to give the leaseholders a full and accurate account of the investigation carried out into the fire, failed to inform them, and indeed other residents, of the operational status of the system and provided them with false assurances about the protection the system would provide in the event of a fire.
156The TMO's review of the action plan dated 20 November 2012
¶43.42 In April 2013, after receiving the leaseholders' complaint, the TMO reviewed Carl Stokes's Record of Significant Findings and Action Plan dated 20 November 2012.1420 TMO review in April 2013 of Carl Stokes's Record of Significant Findings and Action Plan dated 20 November 2012 {MAX00001426}. A version of the Action Plan was produced with an additional column containing comments following a review in April 2013.1421 TMO review in April 2013 of Carl Stokes's Record of Significant Findings and Action Plan dated 20 November 2012 {MAX00001426/1}. In response to his request for confirmation that the smoke ventilation system had been regularly tested and maintained, there is a comment that the TMO had been informed that the vent needed changing and that RGE had said that it could not guarantee that in the event of an emergency the system would work.1422 TMO review in April 2013 of Carl Stokes's Record of Significant Findings and Action Plan dated 20 November 2012 {MAX00001426/7} item 23c. A report was said to have been sent to someone and additional copies were to be provided to Alex Bowman. The action was marked as completed by Ricki Sams.1423 TMO review in April 2013 of Carl Stokes's Record of Significant Findings and Action Plan dated 20 November 2012 {MAX00001426/7} item 23c.
¶43.43 Janice Wray accepted that she had seen that action plan and the findings of the review.1424 Wray {Day144/65:13-17}. The document metadata for the TMO's review of the action plan also states that it was last modified on 4 June 2013 by Janice Wray: {MAX00001426/1}. She accepted, therefore, that from at least April 2013 she had known that the system was not sure to work1425 Wray {Day144/67:4-19}. but she took no steps at that stage to put in place any measures to mitigate the risk it presented.1426 Wray {Day144/67:20-25}. She accepted that it had been her job to make sure that the relevant department was aware of its responsibility to carry out repairs, but she did not accept that she had been responsible for ensuring that the work was in fact carried out, or that she had had the ability to do so.1427 Wray {Day144/68:1-25}. That responsibility lay with the contracts management team, which had the expertise needed to determine what was required.1428 Wray {Day144/68:1-25}. We disagree. Janice Wray, as the competent person, was responsible for overseeing the TMO's compliance with the Fire Safety Order. In particular, she had a responsibility to make sure that the smoke ventilation system was either repaired or, if that was not viable, replaced and mitigating measures put in place pending its replacement.
RGE's inspection of the system in October 2013
¶43.44 RGE carried out a further test of the system on 11 October 2013, which identified the same problems as had been described in its report dated 9 August 2011.1429 RGE engineers' service/maintenance report dated 11 October 2013 {TMO00879757}. The test report stated that the dampers were still not functioning correctly and could not be guaranteed to work correctly in an emergency.1430 RGE engineers' service/maintenance report dated 11 October 2013 {TMO00879757/3}. RGE had provided a quotation for remedial work in May 2010, but the work was evidently still outstanding.1431 RGE maintenance report on the smoke ventilation system at Grenfell Tower dated 12 May 2010 {RBK00013637/8}. It seems that no immediate action was taken to remedy the defects because of the plan to modernise the system as part of the refurbishment. No measures were put in place to mitigate the increased risk presented by those defects pending the completion of that work.
157Maintenance records
¶43.45 On 23 January 2014, Matt Smith of Max Fordham sent an email to Simon Coleman of RGE asking for the test and maintenance records for the smoke ventilation system to assist in formulating a submission to building control on the designs for the proposed new system.1432 Email from Matt Smith to Simon Coleman on 23 January 2014 {MAX00004262/3}. Later that day, Dil Singh of RGE sent him a maintenance report for the system, which, although undated, was the same as the inspection report dated 12 May 2010.1433 Email from Dil Singh to Matt Smith on 23 January 2014 {MAX00004262/1}; Undated RGE maintenance report for the smoke ventilation system at Grenfell Tower {MAX00018264}. Dil Singh told Mr Smith that RGE had told the TMO following every service visit that it could not guarantee that the system would work.1434 Email from Dil Singh to Matt Smith on 23 January 2014 {MAX00004262/1}.
¶43.46 It is not clear why Dil Singh did not give Max Fordham the test reports dated 9 August 2011 and 11 October 2013, given the more serious and recent concerns that they raised about the operation of the system.1435 RGE maintenance report on AOV system at Grenfell Tower dated 9 August 2011 {TMO00894311/5}; RGE engineers service/maintenance report dated 11 October 2013 {TMO00879757/3}. Despite a number of further requests from Matt Smith and Claire Williams between January and March 2014 for the test and maintenance records and for clarity about the current condition of the system, RGE did not provide either.1436 Email from Matt Smith to Dil Singh on 24 January 2014 {MAX00004266/1}; Email from Matt Smith to Claire Williams on 3 February 2014 {MAX00004281/1}; Email from Dil Singh to Claire Williams on 6 February 2014 {MAX00004293}; Email from Duncan Campbell to Claire Williams on 13 February 2014 {MAX00004306}; Email from Duncan Campbell to Claire Williams on 28 February 2014 {MAX00004329}; Email from Claire Williams to Duncan Campbell on 3 March 2014 {EXO00000644}; Email from Claire Williams to Dil Singh on 3 March 2014 {MAX00004330}. It is not clear why, but there is evidence that the TMO had previously experienced problems obtaining documents from RGE.1437 See, for example, email from Gary Mitchell to Peter Maddison on 21 February 2013 {TMO10002270/1}; Emails between Roger Greene and Gary Mitchell on 14 March 2013 {CST00004790}. As it was, RGE's contract came to an end on 31 March 2014.1438 Craig {RGE00000010/1} page 1, paragraph 1; RGE Maintenance Contract {RGE00000004/3} paragraph 3.2.
LFB visit to Grenfell Tower on 12 March 2014
¶43.47 On 12 March 2014, Matthew Ramsey and Ben Dewis, LFB fire safety inspecting officers, and Daniel Hallisey, the local fire station manager, visited Grenfell Tower with Claire Williams and Bruce Sounes.1439 Email from Bruce Sounes to Claire Williams and Janice Wray on 13 March 2014 {TMO10005515/3}. During the visit, consistent with RGE's previous findings, Matthew Ramsey identified that about 25-30 percent of the vents on the smoke ventilation system were not in the correct position.1440 Email from Claire Williams to Janice Wray on 12 March 2014 {TMO10005515/4-5}; Ramsey {LFB00032092/6-7} pages 6-7, paragraphs 19 and 23.2. He was sufficiently concerned about the state of the system to turn his visit into a formal audit and threatened to issue an enforcement notice requiring the TMO to demonstrate within four to six weeks that the system was fully operational.1441 Ramsey {MET00071003/4} page 4; Ramsey {LFB00032092/6} page 6, paragraphs 19-20; Email from Claire Williams to Janice Wray on 12 March 2014 {TMO10005515/5}; Email from Bruce Sounes to Claire Williams and Janice Wray on 13 March 2014 {TMO10005515/3}.
¶43.48 After the visit Claire Williams sent an email to Janice Wray, with a copy to Carl Stokes, telling her of the outcome and suggesting that Ms Wray chase up RGE for the servicing records.1442 Email from Claire Williams to Janice Wray on 12 March 2014 {TMO10005515/4-5}.
158¶43.49 Carl Stokes replied to Claire Williams' email later that day with a copy to Janice Wray. In relation to Matthew Ramsey's concern about the system, he said that the matter had been raised on numerous occasions, but that RGE had failed to provide servicing and maintenance information. He suggested that if the LFB issued an enforcement notice, it would be challenged and that the LFB should be asked to serve it on RGE as the maintenance contractor.1443 Carl Stokes email to Claire Williams on 12 March 2014 {CST00001426/1}.
¶43.50 On 17 March 2014, Carl Stokes visited the tower at the request of Claire Williams to investigate the LFB's concerns.1444 Wray {TMO00000890/10} page 10, paragraph 46. He set out his findings in a letter to her dated 18 March 2014.1445 Letter from Carl Stokes to Claire Williams on 18 March 2014 {CST00003100}. His inspection of the smoke ventilation system appears to have been limited to what he described as the "smoke extract panel", which he said was "showing healthy", and RGE's maintenance logbook, which he appended to his letter.1446 Letter from Carl Stokes to Claire Williams on 18 March 2014 {CST00003100/2}. For reasons which are not clear, the logbook did not contain entries for the tests carried out on 9 August 2011 and 11 October 2013, which Carl Stokes had not seen.1447 The logbook contained only two entries one dated 11/5/2010, which possibly relates to the test report on 12 May 2010, and the other incorrectly dated "15/15/2013", which identified a faulty relay on 15th floor: {CST00003100/14-15}. Carl Stokes interpreted that to mean "15/12/2013" so that the inspection was in date: {CST00003100/2}. There is, however, a separate record of a test to the fire alarm system associated with the smoke ventilation system on 15/05/2013 so, in our view, that is the more likely date: {RGE00000005}. Carl Stokes stated that "the previous loose page in the logbook" was full, but he did not append it: {CST00003100/2}. As a result, he concluded that the logbook showed that RGE had found the system to be generally in working order at the last service.1448 Letter from Carl Stokes to Claire Williams on 18 March 2014 {CST00003100/11}; Carl Stokes said that he understood from RGE's servicing records that the system was functional, notwithstanding Matthew Ramsey's findings, Stokes {Day139/22:19}-{Day139/23:8}.
¶43.51 Carl Stokes said that he had also inspected those parts of the system that were visible, but he did not refer to that in his letter.1449 Stokes {Day139/24:18}-{Day139/25:10}. Nor did he refer to Matthew Ramsey's finding that 25-30 percent of the vents were not working, although he said that he thought he had done so.1450 Stokes {Day139/26:23}-{Day139/27:1}. He recommended that the contractor be asked to service the system sooner rather than later.1451 Letter from Carl Stokes to Claire Williams on 18 March 2014 {CST00003100/11}. Neither Claire Williams nor Janice Wray raised with him the fact that he had not recorded Matthew Ramsey's findings or the fact that his assessment was, on the face of it, at odds with them. Janice Wray did not tell him that RGE had said that it could not guarantee the system would work in the event of the fire, a matter of which she had been aware from at least April 2013.1452 As discussed earlier in this section, see the TMO's review in April 2013 of the Record of Significant Findings and Action Plan dated 20 November 2012 {MAX00001426/7} item 23c.
Notice of deficiencies
¶43.52 On 24 March 2014, the LFB served a deficiency notice on the TMO.1453 LFB Deficiency Notice for Grenfell Tower dated 24 March 2014 {LFB00032101/1}. In summary, it stated that about a quarter of the dampers in the smoke ventilation system were not working, which indicated that it had not been maintained in effective working order.1454 LFB Deficiency Notice for Grenfell Tower dated 24 March 2014 {LFB00032101/3}. It stated that that was a breach of Articles 11(1) and 17(1) of the Fire Safety Order1455 LFB Deficiency Notice for Grenfell Tower dated 24 March 2014 {LFB00032101/3}. and that effective monitoring and maintenance of the system was required to remedy the breach.1456 LFB Deficiency Notice for Grenfell Tower dated 24 March 2014 {LFB00032101/3}. It said those steps should be taken by 5 May 2014.1457 LFB Deficiency Notice for Grenfell Tower dated 24 March 2014 {LFB00032101/1}.
159¶43.53 Matthew Ramsey decided to issue a deficiency notice rather than an enforcement notice because in his experience the TMO, as a responsible person, generally acted on the LFB's advice and could be trusted to take remedial action within the time allowed and because the imminent refurbishment of the building was subject to the oversight of building control.1458 Ramsey {LFB00083855/7} page 7, paragraph 19. When they had spoken after the visit, Janice Wray had satisfied him that there was a plan to replace the system during the refurbishment.1459 Ramsey {LFB00032092/7} page 7, paragraph 23.2; Ramsey {Day147/38:16}-{Day147/39:3}. However, he expected the TMO to ensure that the existing system was working by 5 May 2014, which was necessary to protect both residents and firefighters.1460 Ramsey {Day147/38:1-4}; Ramsey {MET00071003/5} page 5.
¶43.54 In the event, that did not happen. Claire Williams said that it had not been possible to produce a temporary solution to the problem in advance of the refurbishment.1461 Williams {Day121/127:15}-{Day121/128:8}. There is evidence that she thought about that following the receipt of the deficiency notice. For example, in an email to Matt Smith and Bruce Sounes on the 25 March 2014, she said that she was looking at the possibility of fixing the dampers in the open position,1462 Email from Claire Williams to Matt Smith on 25 March 2014 {MAX00004366/3-4}. but Matt Smith advised against that because it would simply allow smoke to spread from floor to floor.1463 Email from Matt Smith to Claire Williams on 25 March 2014 {MAX00004366/3}. Claire Williams had also emailed Michael Lyons on 3 April 2014 about a "temporary option" for the smoke ventilation system: {TMO00856447}. Claire Williams subsequently sent an email to Janice Wray and Alex Bosman on 17 April 2014 suggesting they discuss the options open to the TMO before the time for remedial work allowed by the deficiency notice expired on 5 May 2014. She had already been advised by Max Fordham that the only option available was to carry out the full modernisation work.1464 Email from Claire Williams to Alex Bosman copying in Janice Wray on 22 April 2014 {TMO00856473}. It is not clear whether that discussion ever took place.
¶43.55 Despite the developing recognition that it was not possible to find a temporary solution to the problem, the TMO had the system serviced again, presumably in response to Carl Stokes's recommendation and the deficiency notice.1465 Letter from Carl Stokes to Claire Williams on 18 March 2014 {CST00003100/11}; LFB Deficiency Notice for Grenfell Tower dated 24 March 2014 {LFB00032101/3}. On 17 March 2014, after the LFB had visited Grenfell Tower, Alex Bosman had instructed Colt International Ltd, a company specialising in the design, supply and maintenance of smoke control systems, which serviced smoke ventilation systems in some of the TMO's other properties, to quote for servicing the system.1466 Email from Alex Bosman to Debbie Sanderson on 17 March 2014 {TMO00856389/3}. However, the proposal for servicing that Colt produced on 28 March 2014 does not appear to have been pursued, possibly because the inspection on which it had been based had not identified any of the defects noted by the LFB.1467 Colt service proposal for the smoke ventilation system at Grenfell Tower dated 28 March 2014 {TMO10005654}.
160¶43.56 On 11 September 2014, Simon Lawrence sent an email to Claire Williams asking whether the LFB had returned to check the system after the time allowed in the deficiency notice had expired.1468 Email from Simon Lawrence to Claire Williams on 11 September 2014 {TMO00856902/1-2}. The answer was that it had not. It is evident from that correspondence that almost six months after the deficiency notice, the smoke ventilation system had still not been properly inspected and serviced.
Meeting with Rydon to discuss interim measures
¶43.57 Also on 11 September 2014, Claire Williams sent an email to Janice Wray inviting her to a discussion about the smoke ventilation system on 16 September 2014.1469 Email from Claire Williams to Janice Wray on 11 September 2014 {CST00003178/1}. She explained that Rydon had been working with JS Wright to find an interim solution to the problem. Janice Wray forwarded the email to Carl Stokes and invited him to the meeting as well.1470 Email from Janice Wray to Carl Stokes on 12 September 2014 {CST00003178/1}. That appears to have been the first time the TMO had given any consideration to implementing measures to mitigate the risk presented by the defects in the existing system pending the completion of the refurbishment and the installation of a new system. However, we have not seen any minutes of the proposed meeting and neither Carl Stokes1471 Stokes {Day139/29:24}-{Day139/30:21}. He also did not mention it in his letter to Janice Wray dated 17 September 2014 {CST00030043/9} item 27-28. nor Claire Williams1472 Williams {Day121/138:18}-{Day121/139:8}. had any recollection of it. It is not clear, therefore, whether the meeting actually took place.
Meeting with the LFB fire safety team on 18 September 2014
¶43.58 A progress meeting for the Grenfell Tower project, attended by Claire Williams, was held on 16 September 2014.1473 Grenfell Tower project progress meeting no.3 on 16 September 2014 {TMO00830089}. The minutes of the meeting record that the smoke ventilation system was currently not working. Rydon was asked to try to bring it up to contracted specification as soon as possible. If that was not possible, the system would be returned to the original specification.1474 Grenfell Tower project progress meeting no.3 on 16 September 2014 {TMO00830089/4} item 9.2. The minutes recorded that Claire Williams would keep the LFB informed about the work,1475 Grenfell Tower project progress meeting no.3 on 16 September {TMO00830089/4} item 9.3. but she said that Janice Wray was the main point of contact with the LFB.1476 Williams {Day121/136:3-23}; Williams {Day121/144:9-19}. Claire Williams said that she kept Janice Wray updated as to the progress of the works to the AOV system: Williams {Day121/140:25}-{Day121/141:3}. Janice Wray thought that Claire Williams and the project team were responsible for keeping the LFB informed about the work to the smoke ventilation system.1477 Wray {Day144/54:22}-{Day144/55:10}; {Day144/56:1-7}. Neither of them had a clear understanding of their responsibilities in that respect, but they agreed that the bi-monthly meetings, which they both attended, were the time for informing the LFB fire safety team about the refurbishment. Apart from that, Rydon spoke to the local fire crews when they visited the site.1478 Williams {Day121/141:4-20}; {Day121/144:20}-{Day121/145:8}; Wray {Day144/55:2-10}; {Day144/58:21}-{Day144/59:5}.
161¶43.59 On 18 September 2014, Claire Williams and Janice Wray attended one of the regular meetings with the LFB fire safety team.1479 Minutes of bi-monthly meeting between TMO and LFB fire safety team on 18 September 2014 {TMO10023364}. Ms Williams told them that the smoke ventilation system was to be modernised as a priority. She also drew attention to the fact that while the work was going on the system would not be working at full capacity. That had also been brought to Carl Stokes's attention.1480 Minutes of bi-monthly meeting between TMO and LFB fire safety team on 18 September 2014 {TMO10023364/3} item 6.
¶43.60 According to the minutes of the meeting, neither Claire Williams nor Janice Wray told the LFB that the existing system was not working.1481 Minutes of bi-monthly meeting between TMO and LFB fire safety team on 18 September 2014 {TMO10023364/2-3} item 6. Claire Williams said that the statement that the system "would not be working at full capacity" while the work was going on did not do justice to the state of the existing system, but that the LFB should have known that it was not working because it had issued the deficiency notice.1482 Williams {Day121/149:23}-{Day121/150:7}. The minutes also suggest that the TMO thought about putting in place interim measures only during the modernisation work and did not consider taking steps to mitigate the immediate risk presented by the defects in the existing system.1483 Minutes of bi-monthly meeting between TMO and LFB fire safety team on 18 September 2014 {TMO10023364/3} item 6.
¶43.61 Later that day Claire Williams sent an email to Simon Lawrence telling him that the smoke ventilation system would not be fully operational until after Christmas.1484 Email from Claire Williams to Simon Lawrence on 18 September 2014 {TMO00851824/1}. It is evident from that email that at the meeting the LFB had also made a specific request, which was not reflected in the minutes, that the unavailability of the system during the period of the work should be taken into account in Rydon's and the TMO's fire risk assessments.
¶43.62 On 6 October 2014, Claire Williams told Janice Wray that although the ventilation system would be "in some sort of order" by Christmas, the new extractor fans in the roof plant room would probably not have been fitted, as they would be waiting for building control approval.1485 Email from Claire Williams to Janice Wray on 6 October 2014 {TMO00851844/1-2}. In her response Janice Wray asked whether any steps could be taken to reinstate the ventilation and extraction system, even partially, before it was refurbished.1486 Email from Janice Wray to Claire Williams on 6 October 2014 {TMO00851844/1}. We have not seen a direct response to that email, but it is evident from the subsequent correspondence that it was not considered possible to carry out temporary repairs to the system.
Chubb's inspection
¶43.63 On 29 September 2014, Alex Bosman instructed Chubb Fire and Security to service the smoke ventilation system at Grenfell Tower, which was said to be "out of target".1487 Email from Alex Bosman to Steve Plumridge and Adria Frith copying in Janice Wray and Siobhan Rumble on 29 September 2014 {CST00001451/3}. He also instructed Chubb to contact Carl Stokes, who wished to meet their engineer.1488 Email from Alex Bosman to Adrian Frith copying in Carl Stokes on 29 September 2014 {CST00001451/1}. Mr Stokes met Chubb's engineer at Grenfell Tower on 6 October 2014 to examine the smoke ventilation system, but it seems that he was unable to test it because a fault was showing on the fire alarm panel.1489 Email from Janice Wray to Alex Bosman copying in Carl Stokes on 6 October 2014 {TMO10007591}; Email from Carl Stokes to Alex Bosman on 7 October 2014 {CST00001451/1}. The service certificate, therefore, recorded that further investigation of the system was required.1490 Email from Janice Wray to Alex Bosman copying in Carl Stokes on 6 October 2014 {TMO10007591}. The Inquiry has not been provided with a copy of Chubb's service certificate.
162¶43.64 On 9 October 2014, Alex Bosman sent on to Claire Williams, Janice Wray and Carl Stokes an email that he had sent to Chubb that day, in which he had said that the system had been confirmed as beyond repair and scheduled for replacement shortly.1491 Email from Alex Bosman to Claire Williams, Janice Wray and Carl Stokes on 9 October 2014 {CST00001244/1}. It is not clear whether the description of the system as "beyond repair" came from Chubb's inspection or from Rydon's investigations or something else, but, in any case, in our view, it should have been clear to the recipients of that email that the existing system could neither be temporarily repaired nor maintained pending its modernisation.
¶43.65 Nonetheless, neither Claire Williams nor Janice Wray told the LFB that the existing system was beyond repair, nor did they pass on the information that the completion of the work was likely to be delayed beyond Christmas.1492 Williams {Day121/156:6-18}. When it became clear that the work would not be completed by that time, neither of them sought to implement mitigating measures or to inform the residents that the system was not operating.1493 Williams {Day121/139:10}-{Day121/140:1}; {Day121/156:19}-{Day121/159:18}. Claire Williams had suggested that her concern about the risk to residents had been allayed by the plan to have the system in some kind of working order by Christmas.1494 Williams {Day121/139:10}-{Day121/140:1}; {Day121/142:2-14}. If it was not possible, as had by then become apparent, further measures were required.
The fire risk assessment in October 2014
¶43.66 Carl Stokes carried out a fire risk assessment of Grenfell Tower on 17 October 2014.1495 Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157}. In the section headed "Any other relevant information on this premises" he summarised the three requirements of the deficiency notice and stated that they had been covered in the assessment and accompanying Record of Significant Findings.1496 Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157/7-8}. In respect of the smoke ventilation system, he referred to the LFB's requirement that a system of monitoring should be implemented in relation to the equipment in the lobbies and a maintenance schedule put in place so that the system was kept in good working order.1497 Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157/8}.
¶43.67 Carl Stokes did not refer to the fact that the deficiency notice stated that about a quarter of the dampers were not working and that the system had not been maintained in effective working order.1498 LFB Deficiency Notice for Grenfell Tower dated 24 March 2014 {LFB00032101/3}. Although he did state where the notice could be found, the omission of that information meant that his summary failed to convey the seriousness of the LFB's findings.1499 Carl Stokes disputed in his oral evidence that he had downplayed the seriousness of the situation: Stokes {Day139/42:2-6}.
¶43.68 In section 19 of his fire risk assessment, headed "Fixed Fire Systems and Equipment", he described the smoke ventilation system and recorded that it had been serviced by RGE Services on the 11 October 2013. He also recorded that it was being modernised as part of the refurbishment. However, he did not mention that RGE had said in its service report that it could not guarantee that the system would work; nor did he refer to Matthew Ramsey's findings on 12 March 2014 that 25-30% of the dampers were not working.1500 Email from Claire Williams to Janice Wray on 12 March 2014 {TMO10005515/4}; Email from Bruce Sounes to Claire Williams and Janice Wray on 13 March 2014 {TMO10005515/3}. He did not refer either to the fact that Chubb had been unable to carry out a service of the system on 6 October 2014, or to Alex Bosman's email of 9 October 2014 in which he had described the system as "beyond repair".1501 Email from Alex Bosman to Claire Williams, Janice Wray and Carl Stokes on 9 October 2014 {CST00001244/1}. In short, he failed to address any of the information before him which showed that the system was not working. Despite knowing that, he maintained his assessment that the fire risk at Grenfell Tower was tolerable.1502 Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157/10}. In those respects, his fire risk assessment gave the misleading impression that the system was operational, at least to the extent that it did not affect the overall risk rating for the building.
163¶43.69 Mr Stokes should have recorded in his fire risk assessment that the smoke ventilation system was not working and should have taken account of that in his assessment of the risk.1503 Todd {Day168/31:7}-{Day168/32:23}; Lane {Day172/19:7-12}. He said that he had not referred to the fact that the system was considered to be beyond repair because it was being modernised as part of the refurbishment,1504 Stokes {Day139/35:3-16}. but that did not justify ignoring the fact that it was not then working.1505 Lane {Day172/19:14}-{Day172/20:17}. He also said that, because there was a "stay put" strategy in place, the fact that the system was defective would increase the risk to residents only slightly.1506 Stokes {Day139/35:17}-{Day139/37:23}. Whatever the merits of that suggestion, however, he did not deal with it in his fire risk assessment.
¶43.70 In his accompanying Record of Significant Findings and Action Plan, Carl Stokes stated that Rydon was going to upgrade the existing smoke ventilation system in the lobbies and the refuse chute rooms.1507 Record of Significant Findings and Action Plan dated 17 October 2014 {CST00003177/8} item 19d. He asked what compensatory measures, if any were being put in place whilst the work was being done, but he did not ask whether any measures had been put in place to mitigate the immediate risk presented by the defects in the existing system, nor did he recommend any. He did not include any assessment of the extent to which there were any measures which might adequately mitigate that risk.
¶43.71 Neither Janice Wray nor Claire Williams pointed out to Carl Stokes that he had not dealt in his risk assessment with the failure of the existing system. That was despite the fact that Matthew Ramsey had specifically asked Ms Wray to ensure that Carl Stokes addressed his concerns about the system,1508 Email from Matthew Ramsey to Janice Wray on 14 March 2014 {CST00003115/1}. and despite the LFB's request at the meeting on 18 September 2014 to ensure that the unavailability of the system during the modernisation work was covered in its fire risk assessment.1509 Email from Claire Williams to Simon Lawrence on 18 September 2014 {TMO00851824/1}.
¶43.72 In section 23 of his fire risk assessment, headed "Testing and maintenance", Carl Stokes responded to the question "Is there a monthly testing and annual servicing and maintenance of any automatic opening vents along with any associated equipment/ devices, with records kept?" with the answer "No".1510 Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157/29}. He did not include any comment by way of explanation, even though good practice requires that in such circumstances the fire risk assessor should explain the answer and make a corresponding entry in the action plan.1511 Todd {Day168/34:5}-{Day168/36:3}. Nor did he record that Chubb had been unable to service the system on 6 October 2014,1512 Email from Carl Stokes to Alex Bosman on 7 October 2014 {CST00001451/1}. but he did record that he did not know whether the occupier's tests and inspections of the fire systems within the building were being undertaken.1513 Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157/30}. In his accompanying action plan he recommended that the occupier should carry out weekly tests of the system and record the results.1514 Record of Significant Findings and Action Plan dated 17 October 2014 {CST00003177/9} item 23c.
164¶43.73 That was the fourth time in as many fire risk assessments that Carl Stokes had said that he did not have any information about the maintenance of the smoke ventilation system and had asked for it to be provided. In our view, even though the system was considered to be beyond repair, that was simply not good enough. He ought to have insisted on being given that information before he completed his assessment.1515 Todd {Day168/26:24}-{Day168/27:10}; Lane {Day172/14:14}-{Day172/15:7}; Carl Stokes's Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157/8}. If in October 2014 he had asked directly what had been done in response to his previous recommendations, he might have discovered the chronic nature of the failure to maintain the system and taken account of it in his assessment.
The meeting with the LFB on 13 November 2014
¶43.74 On 12 November 2014, in advance of Janice Wray's meeting with the LFB fire safety team the following day, Claire Williams sent an email to Simon O'Connor asking what it was currently thought could be done to put the smoke ventilation system at Grenfell Tower into working order.1516 Email from Claire Williams to Simon O'Connor on 12 November 2014 {TMO00852028/3}. Simon Lawrence replied the next day saying that the design team had been trying to find a solution which did not involve carrying out work that would later have to be discarded, but that one was unlikely to be available before Christmas.1517 Email from Simon Lawrence to Simon O'Connor and Claire Williams on 13 November 2014 at 08:50 {TMO00852028/1-2}.
¶43.75 Claire Williams did not pass that information to Janice Wray until after her meeting with the LFB that morning,1518 Email from Claire Williams to Janice Wray on 13 November 2014 at 13:59 {TMO00852028/1}. but apparently the subject of the smoke ventilation system had not been raised.1519 Email from Janice Wray to Claire Williams on 13 November 2014 {TMO00852028/1}. However, Ms Wray had been aware from early October that the existing system was beyond repair and that it would, at best, only be partly operational by Christmas, but she did not share that information with the LFB .1520 Email from Claire Williams to Janice Wray on 6 October 2014 {TMO00851844}; Email from Alex Bosman to Claire Williams, Janice Wray and Carl Stokes on 9 October 2014 {CST00001244/1}. Nor did she or Claire Williams pass on the information she had been given by Simon Lawrence to the LFB.1521 Wray {Day144/54:15-20}. There was evidence that the project team was keeping the local LFB operational crew informed, but Janice Wray accepted that she and Claire Williams should have kept the LFB Fire Safety team informed.1522 Wray {Day144/55:2}-{Day144/57:9}.
The Leaseholders' Association complaint, January 2015
¶43.76 On 2 January 2015, the Leaseholders' Association sent an email to Councillor Blakeman and Councillor Dent-Coad seeking confirmation that the smoke ventilation system at Grenfell Tower was going to be replaced as part of the refurbishment.1523 Email from Claire Williams to Janice Wray on 5 January 2015 {TMO00846731}. Later that day, Mr Maddison sent a draft response to Councillor Blakeman, in which he said that the system was currently beyond economic repair and that the TMO was working with building control to agree a design for a system that would meet current standards.1524 Email from Peter Maddison to Councillor Blakeman on 5 January 2015 {TMO10008422}.
165Meeting with the LFB, 20 January 2015
¶43.77 On 13 January 2015, in preparation for a meeting with the LFB on 20 January 2015 Claire Williams asked Matt Smith whether building control had approved the plans for replacing the smoke ventilation system and whether any steps were being taken in the meantime to produce an effective system.1525 Email from Claire Williams to Matt Smith on 13 January 2015 {TMO10042871/2}. Matt Smith said in reply that a technical submission had been prepared comprising a two-stage scheme under which natural ventilation would be reinstated as an interim measure before new pressure differential controls and fans were added later. However, he was unable to say when the work was likely to begin.1526 Email from Matt Smith to Claire Williams on 13 January 2015 {TMO10042871/1}.
¶43.78 The minutes of the meeting on 20 January 2015 suggest that the information obtained from Max Fordham was not passed on to the LFB.1527 Minutes of the bi-monthly meeting between the TMO and LFB fire safety team on 20 January 2015 {TMO00844037}. In the event, only Janice Wray attended the meeting on behalf of the TMO1528 Minutes of the bi-monthly meeting between the TMO and LFB fire safety team on 20 January 2015 {TMO00844037}. and although Claire Williams thought it likely that she had sent Matt Smith's email on to Janice Wray, she could not remember having done so.1529 Williams {Day121/190:3-8}. We are satisfied that she did not send it to the LFB herself.1530 Williams {Day121/190:3-8}. However, even if Janice Wray had not received the email, she was already aware that the work had not been completed and should have drawn that to the attention of the LFB.
¶43.79 On 21 January 2015, Claire Williams told Janice Wray that the first phase of the work, involving the creation of a passive system, was programmed to start on 16 March 2015 and be completed by 1 May 2015 and that the second phase, involving the installation of fans and controls, was programmed to start on 5 May 2015 and be completed by 19 June 2015.1531 Email from Claire Williams to Janice Wray on 21 January 2015 {TMO10042915/2}. It does not appear that either Janice Wray or Claire Williams passed that information on to the LFB at the time.1532 It was provided at the meeting on 23 March 2015: {RBK00013999/3} item 9.
Rydon Fire Risk Assessment, 20 February 2015
¶43.80 On 20 February 2015, Simon Camps and Simon O'Connor of Rydon carried out a project fire risk assessment in relation to Grenfell Tower.1533 Rydon Project Fire Risk Assessment dated 20 February 2015 {RYD00035553/1}.
¶43.81 They identified as a hazard that the detection and alarm systems and the smoke ventilation system did not work.1534 Rydon Project Fire Risk Assessment dated 20 February 2015 {RYD00035553/10}. Each of them was marked as high risk.1535 Rydon Project Fire Risk Assessment dated 20 February 2015 {RYD00035553/10}. Among their recommendations were that the TMO obtain a fire risk assessment that took into account current circumstances.1536 Rydon Project Fire Risk Assessment dated 20 February 2015 {RYD00035553/10}.
166¶43.82 On 18 March 2015, Simon O'Connor sent the fire risk assessment to Claire Williams.1537 Email from Simon O'Connor to Claire Williams on 18 March 2015 {RYD00035549}. She did not notice that Carl Stokes had not addressed those defects in the system in his own risk assessment, nor did she notice the criticism that was made of his assessment.1538 Williams {Day122/10:3}-{Day122/12:21}. Accordingly, she did not ask Carl Stokes to review his assessment to take account of the fact that the smoke ventilation system did not work properly, nor did she ask Janice Wray to do so.1539 Williams {Day122/12:22}-{Day122/13:4}; {Day122/14:11}-{Day122/15:2}. Indeed, she could not recall having given the document to Janice Wray at all.1540 Williams {Day122/15:3-4}.
Further updates to the LFB and delays to the upgrade work
¶43.83 The work to modernise the system did not begin until April 20151541 Emails between Simon O'Connor, Claire Williams and Matt Rawlings on 22-23 April 2015 {TMO00858424}. and the new system was not fully commissioned until 28 April 2016.1542 PSB Above Ground Commissioning Report dated 28 April 2016 {PSB00000224/7}. Janice Wray and Claire Williams kept the LFB informed of the progress of the work during that period.1543 Minutes of the bi-monthly meetings between the TMO and LFB fire safety team on 23 March 2015, 19 August 2015 and 4 March 2016: {RBK00013999/3} item 9; {LFB00000063/4} item 9.1; {TMO10014736/3} item 10.1. The TMO also implemented measures during that period intended to mitigate the risk caused by the absence of a smoke ventilation system while it was being installed. That took the form of familiarisation visits by local fire crews, increased and enhanced inspections by estate staff, health and safety visits, additional inspections by Carl Stokes and preventing contractors from carrying out hot work.1544 Record of Significant Findings and Action Plan dated 17 October 2014 {TMO10017386/9} row 41; Minutes of the bi‑monthly meeting between the TMO and LFB fire safety team on 19 August 2015: {LFB00000063/4} item 9.1.
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