Chapter 54: Fire safety strategies; the contribution of Exova

Introduction

¶54.1 This chapter examines the work done by the fire engineer, Exova, in producing fire safety strategies for Grenfell Tower in connection with the refurbishment.

¶54.2 Exova had been working in the field of fire safety since 1965 and described itself as having established a worldwide reputation for excellence in fire safety.⁴⁹⁵⁴⁹⁵ {TMO10037721/1}; {TMO10003885/1}. In the UK it had offices and facilities in London, Manchester and Warrington and it maintained a presence in other countries around the world.⁴⁹⁶⁴⁹⁶ {TMO10037721/1}; {TMO10003885/1}. Exova had won numerous prestigious awards for its work.⁴⁹⁷⁴⁹⁷ {TMO10037721/1}; {TMO10003885/1}. Due to its access to international experts in the behaviour of materials, fire testing and reaction to fire, Exova described itself (at least to Studio E) as "unique among its peers".⁴⁹⁸⁴⁹⁸ {TMO10037721/2}; {TMO10003885/3}.

¶54.3 Before the refurbishment, Exova had been instructed by Studio E as a consultant on the Kensington Academy and Leisure Centre project.⁴⁹⁹⁴⁹⁹ Sounes {SEA00014273/36} page 36, paragraph 73. As a result, it was instructed by the TMO⁵⁰⁰⁵⁰⁰ {SEA00004789}; {EXO00000543}; Ashton {Day17/19:4-6}. to work on the Grenfell Tower refurbishment,⁵⁰¹⁵⁰¹ TMO's procurement of Exova's services in respect of the Grenfell Tower refurbishment is explored in Chapter 50. but it reported (or at least sent its reports) to Studio E.⁵⁰²⁵⁰² Ashton {Day17/20:1-13}. There was no fresh tender or selection exercise for fire engineering services for the project. Exova was used on the Grenfell Tower refurbishment because it was known and trusted as a result of its work on the KALC project, despite certain misgivings that had been expressed by Neil Crawford of Studio E about the quality and timeliness of that work.⁵⁰³⁵⁰³ {SEA00004051}; Sounes, {Day7/176:1-25}; Crawford, {Day10/8:15-16}.

¶54.4 After Rydon became the principal contractor for the project in April 2014 Exova's existing relationship with the TMO continued. Its services were not transferred to Rydon⁵⁰⁴⁵⁰⁴ {ART00002255/4}; Ashton {EXO00001621/14}; Ashton {Day16/117:2-10}; {Day17/185:2-3}; {Day17/187:7-10}. and the TMO continued to pay its fees,⁵⁰⁵⁵⁰⁵ {EXO00001204}; {EXO00001205}. although the precise scope of its retainer became somewhat unclear and was never clarified by Exova, the TMO or Studio E. In this chapter we set out our findings and conclusions about the work that Exova carried out in relation to the refurbishment.

¶54.5 Before going any further, however, we think it necessary to say something about the evidence given by Dr Barbara Lane, one of the experts instructed by the Inquiry. It was not disputed that Dr Lane is a highly qualified and very experienced fire engineer with a long and distinguished career. She provided a lengthy report for the Inquiry⁵⁰⁶⁵⁰⁶ Lane, Phase 2 Report {BLARP20000017}; Appendix A {BLARP20000018}. A document outlining corrections and addenda {BLARP20000014}. and gave evidence in person over two days.⁵⁰⁷⁵⁰⁷ Lane {Day61/1-224}-{Day62/1-213}. While recognising her expertise, Exova argued in its closing statement on Modules 1 and 2 that she had failed to deal with the evidence accurately, fairly or in a balanced way. It said that some of her criticisms were demonstrably wrong and that some of the evidence in her report fell outside the scope of her expertise.⁵⁰⁸⁵⁰⁸ Exova Closing Submissions {EXO00002124/34} page 34, paragraph 20.2. It urged the Panel to treat her report with great caution and rely on it only insofar as it was necessary to do so and if the evidence was not contentious.⁵⁰⁹⁵⁰⁹ Exova Closing Submissions {EXO00002124/52} page 52, paragraph 27.1.

¶54.6 As we have said, Dr Lane's expertise as a fire engineer was not in dispute. Her work is characterised by meticulous attention to detail and reflects a constant awareness that the responsibility of a fire engineer, particularly in relation to the design of a residential building, is the protection of human life. Her standards are high, but in our view they reflect those that can reasonably be expected of any competent fire engineer. Her evidence may not be beyond criticism, but in general we found her to be a thorough and reliable witness who was careful in her criticisms of Exova and was willing to modify the opinions expressed in her report after she had heard the evidence of the factual witnesses. It is also important to note that Exova did not ask us to hear evidence from a fire engineer expressing opinions that differed from those of Dr Lane. Most of the major criticisms of Exova's work relate to significant omissions from the various documents it produced in the course of its work and its conduct in relation to them. In the main they do not involve minor details but matters of real substance on which Dr Lane was well qualified to express an opinion but on which we have been able to reach our own conclusions. Although we have considered carefully Exova's criticisms of Dr Lane's evidence, we do not consider that we would be justified in rejecting her evidence about the standards to be expected of a reasonably competent fire engineer in relation to the work that Exova was asked to carry out.

Fire Engineering and the purpose of Fire Safety Strategies

¶54.7 Before considering Exova's work on the project we think it may be helpful to explain the role of a fire engineer and the nature and purpose of a fire safety strategy. Dr Lane referred us to recognised definitions of fire engineering and fire engineers. According to the Institution of Fire Engineers (IFE), fire engineering is "the application of scientific and engineering principles, rules, and expert judgment, based on an understanding of the phenomena and effects of fire and the reaction and behaviour of people to fire, to protect people, property and the environment from the destructive effects of fire".⁵¹⁰⁵¹⁰ Lane, Fire Safety Engineer Report {BLARP20000017/17} paragraph 2.6.1; The Institute of Fire Engineers, Frequently Asked Questions Website Page, "What is Fire Engineering?" {INQ00011261}. Further, the IFE defines a "fire engineer" as a person who "through education, training and experience" understands, amongst other things, the "nature, characteristics and mechanisms of fire, the spread and control of fire" and "the likely behaviour of materials, structures, machines, apparatus and processes as related to the protection of life, property and the environment from fire".⁵¹¹⁵¹¹ The Institute of Fire Engineers, Frequently Asked Questions Website Page, "What is Fire Engineering?" {INQ00011261}. Dr Lane was of the opinion that any reasonably competent fire engineer ought as a minimum to have a sound understanding of all those matters.⁵¹²⁵¹² Lane {Day61/9:1}-{Day61/10:7}.

¶54.8 In the context of a residential building fire safety is primarily concerned with the protection and preservation of life. The creation of an effective fire safety strategy therefore calls for high standards of skill, knowledge and professional experience. The fire safety strategy for a building is intended to fulfil a number of purposes. In particular: a. It should address each of the five functional requirements of the Building Regulations in relation to fire (i.e. Functional Requirements B1-B5).

¶b. It should provide a narrative description of the fire safety objectives for the building and how those objectives are to be met, including by means of the active and passive fire safety systems in the building.⁵¹³⁵¹³ Lane {Day61/14:17}-{Day61/15:5}.

¶c. It should describe the characteristics of the building and the people who use it, including the details of its construction, the systems provided for use in the event of fire and the reasons for providing them.⁵¹⁴⁵¹⁴ Lane {Day61/15:10-14}.

¶d. It should explain how the building is to be managed in order to protect persons using it from fire⁵¹⁵⁵¹⁵ Lane {Day61/19:6-23}. and identify any fire risks which have either been mitigated or which it is not possible to mitigate.⁵¹⁶⁵¹⁶ Lane {Day61/15:25}-{Day61/16:3}. Published Document 7974:2002 also states: "The fire safety strategy for the building will be based on the successful trial design and is likely to comprise a range of physical fire safety measures and management procedures. A description of these measures should be provided, together with performance specifications and any recommended deviations from the relevant system codes."Show full note

¶e. It should be written in a way that enables those managing and occupying the building to have a clear understanding about what fire protection and prevention measures are present, how they need to maintain them and how they need to educate people on what to do in the event of fire. It should also be capable of being easily understood by the Fire and Rescue Service so that firefighters are aware of the measures that have been provided for them and why.⁵¹⁷⁵¹⁷ Lane {Day61/15:16-24}; {Day61/44:25}-{Day61/45:17}.

¶f. It should identify the fire safety performance requirements on which those responsible for the design of the building can rely. As Mr Ashton accepted,⁵¹⁸⁵¹⁸ Ashton {Day16/49:12-16}. the fire safety strategy is the founding source of the required performance criteria for the architect's fire drawing information and for other parties responsible for the design of fire safety systems.⁵¹⁹⁵¹⁹ Lane, Phase 2 Report {BLARP20000017/48} paragraph 3.6.8; Lane {Day 61/23:10}-{Day61/24:2}.

¶54.9 Dr Lane drew attention to the Fire Industry Association (FIA) Guidance Note "Scope of Works for the Fire Engineer",⁵²⁰⁵²⁰ {INQ00011219}. dated May 2015, which she considered reflected good industry practice and had done so for many years before its publication.⁵²¹⁵²¹ Lane {Day61/24:12}-{Day61/25:12}. It makes clear that any fire safety strategy should address all relevant design questions relating to fire safety, including "surface spread of flame requirements for surface materials",⁵²²⁵²² {INQ00011219/4}. "fire compartmentation requirements, including fire-stopping and cavity barriers"⁵²³⁵²³ {INQ00011219/4}. and "external fire spread".⁵²⁴⁵²⁴ {INQ00011219/4}. Again, Mr Ashton accepted that those were matters that ought to be included in any fire strategy.⁵²⁵⁵²⁵ Ashton {Day16/44:9-{Day16/47:3}.

¶54.10 The FIA Guidance Note also makes it clear that the work of a fire engineer will often be linked to the RIBA Stages of Work. Dr Lane explained that a fire engineer has an important role before each of the RIBA stage reports are produced, so that the fire safety strategy, the architect's reports and the mechanical and electrical services reports at the end of each RIBA stage are aligned.⁵²⁶⁵²⁶ Lane {Day61/131:21}-{Day61/132:25}. It followed, in her opinion, that the RIBA stage reports produced by the architect on any project were "significant milestone documents" for a fire engineer and that any reasonably competent fire engineer would know that it was necessary to read them in full,⁵²⁷⁵²⁷ Lane {Day61/131:8}-{Day61/133:11}. or at least to review them and digest all aspects that were relevant to fire safety.⁵²⁸⁵²⁸ Lane {Day61/177:7-19}.

¶54.11 In the view of Dr Lane, a fire safety strategy for an existing building is a particularly important document and preparing it is a more demanding piece of work than working on a new project.⁵²⁹⁵²⁹ Lane {Day61/28:5}-{Day61/35:13}; Lane, Phase 2 Report {BLARP20000017/49-50} paragraphs 3.6.20-3.6.23. At the time in question guidance on how to create a fire safety strategy for an existing building was to be found in PAS 911:2007,⁵³⁰⁵³⁰ {BSI00000066}; PAS stands for Publicly Available Specification. which contained a step-by-step guide, including guidance on the research and site activities required and on the need for discussion with stakeholders before the document is finally approved.⁵³¹⁵³¹ Lane {Day61/30:15}-{Day61/35:10}.

¶54.12 The fire safety strategy is also an important document for the purposes of carrying out a suitable and sufficient fire risk assessment under the Fire Safety Order.⁵³²⁵³² Lane {Day61/21:15-17}; See PAS 911:2007 {BSI00000066/37-38} paragraph 7.1.3; Lane, Phase 2 Report {BLARP20000017/338} paragraph 14.1.38; Lane {Day61/36:12}-{Day61/39:7}. Conversely, any fire risk assessment of that kind is an important source of information for a fire engineer preparing a fire safety strategy for an existing building, since it should contain information about the characteristics of the building and the people using it.⁵³³⁵³³ Lane {Day61/39:8-21}. The results of investigations undertaken to produce an existing fire safety strategy will also provide significant information for the purpose of a fire risk assessment.⁵³⁴⁵³⁴ Lane, Phase 2 Report {BLARP200000017/117} paragraph 5.4.19; Lane {Day61/40:4-15}.

¶54.13 Having regard to the nature of a fire safety strategy, we accept Dr Lane's evidence that any reasonably competent fire engineer instructed to produce such a strategy for the Grenfell Tower refurbishment would have appreciated that they were a "designer" within the meaning of the CDM Regulations 2007. Preparation of a fire safety strategy is part of the design process which routinely includes the production of drawings, design details and specifications, including fire performance specifications.⁵³⁵⁵³⁵ Lane {Day62/80:25}-{Day62/82:18}; Lane, Phase 2 Report {BLARP200000017/249} paragraphs 14.1.16-14.1.10; See Regulation 2 of the CDM Regulations 2007 and the definitions of "design" and "designer". As a designer preparing a fire safety strategy, a fire engineer is under a duty to take reasonable steps to avoid foreseeable risks to the health and safety of any person liable to be affected by the construction work, including the residents of any occupied building undergoing refurbishment work.⁵³⁶⁵³⁶ CDM Regulations 2007, Regulation 11(2)-(3).

Exova's early involvement in the Grenfell project

¶54.14 In early April 2012 Studio E began to send Exova information about the Grenfell Tower refurbishment project, including architectural drawings. At that stage it was seeking an initial assessment of the proposed fire escape strategies for the layout proposals contained in the drawings.⁵³⁷⁵³⁷ {EXO00001743}.

¶54.15 On 19 April 2012 James Lee attended a design team meeting at which Bruce Sounes made it clear that the refurbishment would include the overcladding of the entire building.⁵³⁸⁵³⁸ {EXO00001744/4} sections 5 and 6. There was some discussion about the budget for the cladding.⁵³⁹⁵³⁹ {EXO00001744/4} sections 5 and 6. At that point, therefore, Exova ought to have understood, at least in general terms, what the refurbishment involved.

¶54.16 On 3 May 2012 Mr Sounes sent an email⁵⁴⁰⁵⁴⁰ {EXO00001745}. to Terence Ashton and James Lee attaching some site photographs and setting out the likely scope of the project. As well as various works to the lower levels of the tower, the scope of works included overcladding. Mr Sounes asked for a fee proposal from Exova for the works, broken down into RIBA Stages C, D, E, F "and beyond (if required)" and a summary of what Exova would be doing at each stage.

¶54.17 On 9 May 2012 Mr Ashton responded with a fee proposal for the provision of consultancy services which included the creation of an outline fire safety strategy for the refurbishment.⁵⁴¹⁵⁴¹ {EXO00000164}. The proposal quoted a fee of £3,300 for RIBA Stage C and £5,300 for RIBA Stages D-E. It was eventually accepted by Artelia on behalf of the TMO on 1 November 2012.⁵⁴²⁵⁴² Email from David Hale to Margaret Treanor (Exova) on 1 November 2012 {EXO00000540} attaching approval of the Fee Proposal in the form of an email from Paul Dunkerton (TMO) {EXO00000541} together with invoicing instructions {EXO00000542}. Confirmation of approval of this fee proposal was sent to Terry Ashton on 18 July 2012 {ART00006294} and also sent to Dr Clare Barker on 24 July 2012 {ART00000184}.Show full note

¶54.18 On 21 May 2012 Bruce Sounes asked Exova for some advice about the feasibility of certain proposals for the works for the purposes of RIBA Stage C.⁵⁴³⁵⁴³ {EXO00001748}. Mr Ashton responded on 22 May 2012 with some initial comments. He explained that the proposed alterations "must not adversely affect [the building] in relation to compliance with the requirements of Part B (fire safety)". He also said that a site visit would be very helpful in understanding the existing condition of the building.⁵⁴⁴⁵⁴⁴ {EXO00001748}. Mr Sounes found Mr Ashton's comments "difficult to follow",⁵⁴⁵⁵⁴⁵ Sounes {Day7/201:3-6}. and replied attaching some photographs, inviting Mr Ashton to a design team meeting and suggesting that a site visit was essential.⁵⁴⁶⁵⁴⁶ {EXO00000685}.

¶54.19 Mr Lee visited the tower on 29 May 2012 and took a number of photographs.⁵⁴⁷⁵⁴⁷ {EXO00001749}. Thereafter there were exchanges between Studio E and Exova focusing on the lower levels of the tower where there was a proposed change of use.⁵⁴⁸⁵⁴⁸ {EXO00001750}; {EXO00001751}; Lee {EXO00001740/3} page 3, paragraph 3.9. Following his visit, Mr Lee sent Studio E a series of marked-up drawings with comments on the proposed refurbishment works.⁵⁴⁹⁵⁴⁹ {SEA00000022}; {SEA00004324}.

¶54.20 On 11 June 2012, Mr Lee sent Mr Sounes a fee proposal for the production of an Existing Fire Safety Strategy that would relate to the building in its existing state. It set out a detailed scope of work and proposed a fixed lump sum fee of £2,865.⁵⁵⁰⁵⁵⁰ {TMO10037721/2}.

¶54.21 Mr Lee left Exova on 20 July 2012 before the proposal had been accepted. He was not involved in the preparation of the Existing Fire Safety Strategy and had no further involvement in the refurbishment project.⁵⁵¹⁵⁵¹ Lee {EXO00001740/4} page 4, paragraph 3.15-3.16.

The Existing Fire Safety Strategy

¶54.22 On 26 July 2012 Dr Clare Barker, a Principal Consultant at Exova, attended a Grenfell project meeting at the invitation of Bruce Sounes.⁵⁵²⁵⁵² {EXO00000242}. Dr Barker had had no previous involvement with Grenfell Tower and Exova's emails at the time recorded that she had "drawn the short straw" in having to attend. She explained that she was based in the Warrington office and had to cover the work because others within Exova were too busy.⁵⁵³⁵⁵³ Barker {Day15/19:24}-{Day15/20:23}. At the meeting there were references to the overcladding. Attention was drawn to the absence of an existing fire safety strategy for the building.⁵⁵⁴⁵⁵⁴ See Minutes of Project Meeting (Number 5) on 26 July 2012 page 4, where the following appears (under the heading Quantity Surveyor), "There is no existing fire strategy for the building. Exova to proceed." {EXO00001620/4}. There was no discussion of the scope of work required to produce one, but the minutes show that Exova was instructed to proceed with it.

¶54.23 In subsequent exchanges with Mr Sounes in late July 2012 Dr Barker indicated that she aimed to get the Existing Fire Safety Strategy to Studio E by 16 August 2012.⁵⁵⁵⁵⁵⁵ Barker {EXO00001603/2-3} pages 2-3, paragraph 3.7. (Mr Ashton was off sick at that point, as he had been for some four weeks.)⁵⁵⁶⁵⁵⁶ Ashton {Day16/66:17-22}. However, it was not until 7 August 2012 that she instructed Cate Cooney to produce a first draft. Ms Cooney had produced existing fire safety strategies for only a small number of buildings since joining Exova and was not sure how many of those had been for high-rise residential blocks.⁵⁵⁷⁵⁵⁷ Cooney {Day14/37:15}-{Day14/38:4}.

¶54.24 On 7 August 2012, as part of her initial instructions, Dr Barker sent Ms Cooney Mr Sounes' email of 30 July 2012, together with some drawings.⁵⁵⁸⁵⁵⁸ {EXO00001613}. Her email simply said "See below." Since they sat close to each other in the Warrington office, there were frequent, informal and unrecorded conversations between them and Dr Barker's email probably followed an informal instruction to start the process of preparing a draft strategy.⁵⁵⁹⁵⁵⁹ Cooney {Day14/30:3-9}.

¶54.25 Ms Cooney said that the information she had initially been given was limited.⁵⁶⁰⁵⁶⁰ Cooney {EXO00001590/3} page 3, paragraph 3.6; Cooney {Day14/30:20-22}; {Day14/80:24}-{Day14/87:18}. At that stage she had not known the identity of the ultimate client; she knew only that she was producing a report for Studio E.⁵⁶¹⁵⁶¹ Cooney {Day14/34:6-17}. She could not recall having seen the fee proposal at any time before she had begun preparing her evidence for the Inquiry.⁵⁶²⁵⁶² Cooney {EXO00001590/2} page 2, paragraph 3.4; Cooney {Day14/52:4-13}.

¶54.26 As well as the drawings that Dr Barker had sent her, Ms Cooney obtained copies of the original plans of Grenfell Tower on microfiche from Studio E.⁵⁶³⁵⁶³ Cooney {EXO00001590/3} page 3, paragraph 3.6; Cooney {Day14/80:2-16}. On 9 August 2012 she also asked Mr Sounes about certain features of the building, including whether there was a fire-fighting lift.⁵⁶⁴⁵⁶⁴ {EXO00001592}. He told her that there was not.⁵⁶⁵⁵⁶⁵ {EXO00001593/3} and {EXO00001593/2}; Lane, Fire Safety Engineer Report (Version 2) {BLARP20000017/140}. However, three or four days later she received from the TMO a copy of the fire risk assessment dated 29 December 2010 prepared by Carl Stokes ("the 2010 fire risk assessment"),⁵⁶⁶⁵⁶⁶ {TMO10037743}. which wrongly described the lifts as "fire-fighting lifts".⁵⁶⁷⁵⁶⁷ {TMO10037743/4}. Ms Cooney noticed the inconsistency in the information before her but did not seek to resolve it,⁵⁶⁸⁵⁶⁸ Lane {Day61/84:15}-{Day61/86:6}. choosing instead to prefer what was said in the fire risk assessment because it was what she described as a "regulatory document" (i.e. prepared to enable the TMO to comply with its obligations under the Fire Safety Order) and, therefore, a more reliable source of information.⁵⁶⁹⁵⁶⁹ Cooney {Day14/189:22}-{Day14/192:7}, especially at {Day14/190:5-13}. In our view that was a mistake. The distinction between a fire lift and a firefighting lift⁵⁷⁰⁵⁷⁰ Phase 1 Report, paragraph 34.11. is important and a reasonably competent fire engineer would have taken steps to clarify the matter by obtaining some independent authoritative information.⁵⁷¹⁵⁷¹ Lane {Day61/85:9-25}. She denied that she had failed to do so because she was in a hurry to get the document finished before the 16 August deadline,⁵⁷²⁵⁷² Cooney {Day14/191:2-7}. but we think that the short deadline for the work is likely to have played at least some part in it.

¶54.27 For some reason Cate Cooney was not sent the Significant Findings and Action Plan referred to at the foot of page 1 of the 2010 fire risk assessment, nor did she ask to see them.⁵⁷³⁵⁷³ {CST00000091}. She did not visit the building, despite the fact that the fee proposal provided for a site visit and that she had difficulty understanding its layout from the drawings alone. As a result, there were numerous gaps in the information available to her which led her to make a wide variety of assumptions about its state. Ms Cooney did not even have a copy of the Fee Proposal, which, although a largely standard document, would have acted as an aide memoire for what she was to do. If she had obtained a copy, as required by internal Exova guidance,⁵⁷⁴⁵⁷⁴ {EXO00001224/1-2} section 4. she could have used it as a checklist.

¶54.28 Ms Cooney had available to her the photographs taken by James Lee when he had visited the building in May 2012⁵⁷⁵⁵⁷⁵ Cooney {Day14/90:20}-{Day14/91:12}. and she discussed the layout of the building and other matters (including the smoke control system) with him following his visit.⁵⁷⁶⁵⁷⁶ Cooney {Day14/67:3-5}; Cooney {EXO00001590/3} page 3, at paragraph 3.7. However, when he left Exova James Lee left behind no notes of his site visit and it seems likely that he had intended to visit the tower again, because he provided for a half-day site survey in the fee proposal. Although Ms Cooney said that she took notes of her discussion with him, she was unable to produce any⁵⁷⁷⁵⁷⁷ Cooney {Day14/87:14}-{Day14/89:5}. and there is no reference in the contemporaneous documents to a discussion of that kind. We think it unlikely, therefore, that any detailed discussion about the building took place between Ms Cooney and Mr Lee for the purposes of preparing the Existing Fire Safety Strategy. Dr Barker confirmed that she had not spoken to Mr Lee about his visit to the tower, he having left Exova before her involvement in the project.⁵⁷⁸⁵⁷⁸ Barker {Day15/37:19-22}.

¶54.29 In its fee proposal Exova had described itself as having a worldwide reputation for excellence in fire safety⁵⁷⁹⁵⁷⁹ {TMO10037721/1}; {TMO10003885/1}. and as being unique among its peers in its access to international experts in the behaviour of materials, fire testing and reaction to fire.⁵⁸⁰⁵⁸⁰ {TMO10037721/2}; {TMO10003885/3}. By appointing Exova, therefore, the TMO and Studio E could reasonably have expected to have access to high-quality fire engineering advice from leaders in the field. In Dr Lane's opinion, any company holding itself out as providing the highest quality of fire engineering services ought to ensure that its work has the approval of a qualified Chartered Fire Engineer who has undergone the minimum training required by the Engineering Council.⁵⁸¹⁵⁸¹ Lane {Day61/66:10-25}. In the event, Dr Barker was the only member of Exova's staff engaged on the Grenfell Tower project who was qualified as a Chartered Engineer,⁵⁸²⁵⁸² A Chartered Engineer is a person who has been registered as a professional engineer in accordance with the requirements of the Engineering Council. The Fire Engineering Council of the Fire Industry Association is the only body that currently has a process for assessing the competence of fire engineers. It confers the qualification of Chartered Fire Safety Engineer through the chartership process overseen by the Engineering Council. See Lane {Day61/46:6}-{Day61/49:23}.Show full note and her involvement was limited to a cursory review of the draft Existing Fire Safety Strategy produced by Ms Cooney.

¶54.30 On 15 August 2012 Ms Cooney sent the draft Existing Fire Safety Strategy by email to Dr Barker for review, saying that she had printed off drawings for her assistance.⁵⁸³⁵⁸³ {EXO00000175}; Cooney {EXO00001590/3} page 3, paragraph 3.8. She did not send Dr Barker either the 2010 fire risk assessment or copies of her email correspondence with Mr Sounes but she may have printed them off and left them on Dr Barker's desk, because Dr Barker said that she thought she had seen the fire risk assessment when she reviewed Ms Cooney's draft.⁵⁸⁴⁵⁸⁴ Barker {Day15/72:4-10}.

¶54.31 There is reason to think that Ms Cooney may not have devoted as much time to the task as might normally have been expected. She was working under pressure because she had told Studio E that the document would be ready by 16 August 2012 and was due to go on holiday on 17 August 2012. She said that she would normally expect to take between a few days and a week to complete a task of that kind, but in this case the records show that it occupied no more than 15 chargeable hours of her time. Even allowing for the fact that she may have spent more time on it than the records show, they suggest that she completed the work rather more hurriedly than one would have expected.⁵⁸⁵⁵⁸⁵ {EXO00001353}; Cooney {Day14/194:3}-{Day14/195:7}.

¶54.32 On 16 August 2012, almost exactly 24 hours later, Dr Barker replied to Ms Cooney's email in the following terms: "I have reviewed it and it is fine."⁵⁸⁶⁵⁸⁶ {EXO00000175}. Dr Barker said that she had reviewed the draft together with the drawings, but she could not remember in how much detail she had considered the drawings themselves, nor whether she had reviewed all of them, nor even whether she had checked the measurements.⁵⁸⁷⁵⁸⁷ Barker {Day15/71:2-15}. Nor could Dr Barker remember how long she had spent reviewing the report, although she thought that it must have been a couple of hours.⁵⁸⁸⁵⁸⁸ Barker {Day15/73:10-13}. She said that she would usually give a more detailed response and could not remember why she had not done so on that occasion.⁵⁸⁹⁵⁸⁹ Barker {Day15/80:11-14}.

¶54.33 Dr Barker accepted that 16 August was her last day in the office before she went on holiday and that she had a number of other matters to finish before she left.⁵⁹⁰⁵⁹⁰ Barker {Day15/73:20-22}; {Day15/128:10-16}. It is hard to know exactly how long she spent considering the document, but the fact that the Exova summary of timesheets for the project do not record any time spent by Dr Barker on a peer review suggests that it was very little. If, as she hinted, she had deliberately posted the time she spent on it to another project for a different client,⁵⁹¹⁵⁹¹ Barker {Day15/78:8-10}. that would have been a serious failing in the billing system and quite improper, and even an inadvertent failure to post the time to the correct account would have been surprising. There is no reliable evidence to suggest that either of those events occurred and, viewing the evidence as a whole, we think it most likely that in fact Dr Barker spent too little time considering the draft to justify billing the client.

¶54.34 At that stage the document created by Ms Cooney was a first draft; indeed, throughout her evidence she made it clear that she had only been instructed to produce a draft,⁵⁹²⁵⁹² Cooney {Day14/30:3-9}. which was one of the explanations she gave for the many assumptions and qualifications it contained. Ms Cooney sent the document to Mr Sounes by email later on 16 August 2012.⁵⁹³⁵⁹³ {EXO00001396}. On 16 August 2012, only a few minutes after Dr Barker had approved the draft, Ms Cooney sent it to the Exova administration team to format before being circulated. She asked Dr Barker to authorise her signature on it. Cooney {EXO00001590/3} page 3, paragraph 3.10; {EXO00000577}. Dr Barker did so straight away {EXO00000158}, and Ms Cooney immediately sent it to Mr Sounes. She told him that she was going on holiday the next day and that if he wanted to discuss it he should telephone her before then. She thus gave him at most 24 hours to discuss it. The document remained watermarked "DRAFT" throughout.Show full note

¶54.35 On 17 August 2012, Cate Cooney and Bruce Sounes had a telephone conversation⁵⁹⁴⁵⁹⁴ {EXO00001279}. but it is likely that their conversation related to aspects of the refurbishment other than the draft Existing Fire Safety Strategy.⁵⁹⁵⁵⁹⁵ {SEA00000043}. On 30 August 2012, Mr Sounes sent an email to Mr Ashton, with a copy to Dr Barker saying that he needed to go through the draft Existing Fire Safety Strategy,⁵⁹⁶⁵⁹⁶ {SEA00000048}. but in the event no discussion ever took place. Why it did not remains unclear. Exova operated a Project Completion Procedure under which the project manager was required to make a careful note of the scope of services described in the contract documentation⁵⁹⁷⁵⁹⁷ {EXO00001224}. and check that all elements of the project had been completed satisfactorily. Dr Barker did not have a good recollection of the procedure,⁵⁹⁸⁵⁹⁸ Barker {Day15/83:9}. although she appears to have been aware of its existence. However, she said that it did not apply at that stage because at that time the document was still no more than a draft.⁵⁹⁹⁵⁹⁹ Barker {Day15/85:1-15}.

¶54.36 After the draft Existing Fire Safety Strategy had been sent to Studio E it was still not clear who within Exova was responsible for it. Dr Barker thought that Mr Ashton had assumed responsibility for it; Mr Ashton assumed that Ms Cooney and Dr Barker were dealing with it. Ms Cooney said that it had been handed back to colleagues who were dealing with the project overall.⁶⁰⁰⁶⁰⁰ Barker {Day15/94:11-15}; Ashton, {Day16/139:20-23}; {Day16/145:3-7}; {Day16/145:11-14}; {Day16/146:5-18}; {Day16/145:3-7}; Cooney {Day14/205:18-23}. Mr Ashton admitted that there had been a misunderstanding between the Exova employees,⁶⁰¹⁶⁰¹ Ashton {Day16/152:13-18}. but said that he "didn't think it was that important", given that there were other strands to Exova's work on the building at the time.⁶⁰²⁶⁰² Ashton {Day18/10:10}-{Day18/11:3}. Somewhat surprisingly, Mr Ashton was not aware that the Existing Fire Safety Strategy was meant to provide the basis on which a fire safety strategy for the refurbishment was to be constructed.⁶⁰³⁶⁰³ Ashton {Day18/11:4-7}. The draft Existing Fire Safety Strategy sent to Bruce Sounes on 16 August 2012 was never finalised and the review intended to verify the assumptions it contained and provide the missing information did not take place.

¶54.37 At a project meeting on 6 September 2012 attended by Mr Ashton and Mr Sounes it was agreed that the draft Existing Fire Safety Strategy required "detailed interrogation"⁶⁰⁴⁶⁰⁴ {ART00000404}. but when they met on 10 September 2012 they did not consider it in any detail,⁶⁰⁵⁶⁰⁵ Ashton {Day 16/151:21-25}. since Mr Ashton did not see the meeting as part of the process of getting the draft to the final stage.⁶⁰⁶⁶⁰⁶ Ashton {Day16/152:4-6}. He did not view the completion of the Existing Fire Safety Strategy as his responsibility and regarded it simply as a record of what was there.⁶⁰⁷⁶⁰⁷ Ashton {Day16/145:3-7}.

¶54.38 Fortified by the opinion of Dr Lane, we are satisfied that the draft Existing Fire Safety Strategy was based on an extremely brief (two-hour) site visit, was completed without the benefit of detailed site inspection notes, was based on unsubstantiated assumptions,⁶⁰⁸⁶⁰⁸ Lane {Day61/72:3-18}; {Day61/77:18}-{Day61/78-13}; {Day61/78:6-8}; {Day61/80:6-9}; {Day61/91:3-24}; {Day61/95:7-18}; {Day61/99:8}-{Day61/104-4}. and failed to identify the relevant regulatory guidance.⁶⁰⁹⁶⁰⁹ Lane, Phase 2 Report {BLARP20000017/157} paragraph 5.7.1(e). See also {BLARP20000017/127} in relation to Cate Cooney's paragraph 3.2.1; Exova provided incorrect guidance on the spread of fire across internal linings (copying incomplete guidance from Approved Document B) and distance from the main fire outlet. Lane, Phase 2 Report {BLARP20000017/158} Table 5-10; {BLARP20000017/158} paragraph 5.7.1(q)).Show full note The fee quoted (£2,865 plus VAT) represented about three-and-a-half days' work, which was insufficient for a task of that magnitude.⁶¹⁰⁶¹⁰ Lane, Phase 2 Report {BLARP20000017/61} paragraph 4.3.46; Lane {Day61/72:1-18}. Dr Lane considered that four to six weeks' work would have been more appropriate.⁶¹¹⁶¹¹ Lane {Day61/74:23-25}. A site visit lasting only two hours was in her view wholly insufficient to make a meaningful appraisal of the fire safety features of a building of the scale and condition of Grenfell tower.⁶¹²⁶¹² Lane, Phase 2 Report {BLARP20000017/88} paragraph 4.7.14; See also Lane, Phase 2 Report {BLARP20000017/336} paragraph 14.1.21. She would have expected two people to spend at least a day on site.⁶¹³⁶¹³ Lane {Day61/78:17-19}. While she thought that it would have been reasonable for Ms Cooney to have relied on Mr Lee's site visit if it been well documented,⁶¹⁴⁶¹⁴ Lane {Day61/79:3-8}. that was not the case; there were no site notes or marked-up drawings, and the photographs,⁶¹⁵⁶¹⁵ {EXO00001749}. These photographs are not acknowledged or used as part of the existing building fire safety strategy report. according to Dr Lane, were difficult to interpret since they were not accompanied by any information or explanation.⁶¹⁶⁶¹⁶ Lane {Day61/80:14-21}; Lane, Phase 2 Report {BLARP20000017/255} paragraph 8.3.1; Lane {Day61/81:17-24}. See also Lane, Phase 2 Report {BLARP20000017/336} paragraph 14.1.19. There is no evidence that Mr Lee inspected the fire compartmentation during his visit, an omission which Dr Lane considered to be of crucial significance, given that the "stay put" strategy at Grenfell Tower was wholly reliant on a high degree of compartmentation.⁶¹⁷⁶¹⁷ Lane, Phase 2 Report {BLARP20000017/146} paragraphs 5.4.28-5.4.29.

¶54.39 Dr Lane considered that the information available to Ms Cooney had been too limited to enable her to draft an effective fire safety strategy for the existing building.⁶¹⁸⁶¹⁸ Lane {Day61/83:24-25}. In her opinion Ms Cooney ought to have listed all the information that was not available to her and set out clearly what was needed in order to analyse the building properly.⁶¹⁹⁶¹⁹ Lane {Day61/84:6-13}; {Day61/121:1-7}. That would have included relevant fire safety policies, fire safety management policies and maintenance records.⁶²⁰⁶²⁰ Lane {Day61/84:15}-{Day61/85:7}. In addition, Dr Lane pointed out that Exova had not identified within the draft Existing Fire Safety Strategy any of the shortcomings or assumptions in the 2010 fire risk assessment made by Carl Stokes. She was critical of Ms Cooney's failure to ask for the Significant Findings which formed part of Mr Stokes' 2010 fire risk assessment and of her decision to go ahead without them. Nor had Exova explained the steps it had taken to satisfy itself that the contents of that 2010 fire risk assessment were based on an accurate assessment of the condition of Grenfell Tower, something which Dr Lane would have expected a competent fire engineer to have done.⁶²¹⁶²¹ Lane, Phase 2 Report {BLARP20000017/147} paragraphs 5.4.39-5.4.40. In her view, the proposed Existing Fire Safety Strategy was akin to an independent audit of the existing building and any differences between the strategy and the fire risk assessment, such as the status of the lifts, were important matters to identify.⁶²²⁶²² Lane {Day61/120:8-14}.

¶54.40 In Dr Lane's opinion, Ms Cooney's failure to carry out that step meant that, even as a draft, the document was wholly inadequate. It did not constitute a record of the condition of the existing building, could not be used as the basis of a fire risk assessment for the purposes of the Fire Safety Order, and could not inform the necessary mitigation measures in the refurbishment strategy.⁶²³⁶²³ Lane, Phase 2 Report contains a list of defects in the Existing Fire Safety Strategy and their effect {BLARP20000017/157} paragraphs 5.7.1-5.7.6. Dr Lane confirmed that the evidence of Ms Cooney and Dr Barker had not caused her to change her opinions: Lane {Day61/130:23}-{Day61/131:2}. The document did not adequately identify what further investigation was needed, nor did it provide an explanation of how Exova had taken the missing information into account in its overall assessment of the risk.⁶²⁴⁶²⁴ Lane, Phase 2 Report {BLARP20000017/157}. It did not warn the reader that until that information had been obtained it was unsafe to rely on the document.

¶54.41 Among the salient omissions identified by Dr Lane were the following: a. The document did not state whether the means of escape were sufficient to satisfy

the requirements of Article 14 of the Fire Safety Order⁶²⁵⁶²⁵ Which deals with emergency routes and exits from a building. and therefore did not provide the responsible person with practical guidance on that topic.⁶²⁶⁶²⁶ Lane, Phase 2 Report {BLARP20000017/129}.

¶b. It did not tell the TMO what action needed to be taken under the Fire Safety Order in response to the existing condition of the building,⁶²⁷⁶²⁷ Lane, Phase 2 Report {BLARP20000017/336} paragraphs 14.1.22-14.1.23; Lane {Day61/115:14}-{Day61/116:17}. in particular, in relation to the condition of the doors, the inoperability of the smoke control system and the status of the lifts.⁶²⁸⁶²⁸ Lane {Day61/116:6-10}.

¶c. It contained no assessment of the width of the stairs or of the performance of the front doors to the flats, the doors to the stair or the lift doors. (Ms Cooney did not understand that to fall within the scope of her instructions.)⁶²⁹⁶²⁹ Cooney {Day14/171:20}.

¶d. No sketches or drawings were provided to enable the reader to understand how the text related to the building.⁶³⁰⁶³⁰ Lane, Phase 2 Report {BLARP20000017/158} paragraph 5.7.1(p).

¶e. The document contained no consideration of the characteristics of the people who occupied the building and no evaluation of the needs of those who required assistance to evacuate in the event of a fire.⁶³¹⁶³¹ Lane {Day62/83:13}-{Day62/96:1}; See the relevant provisions of ADB {CLG00000173/14} section 0.19 and {CLG00000173/18} paragraph B1.v, including the Note.

¶54.42 We have already explained why we accept the evidence of Dr Lane both in relation to the standard of work to be expected of a reasonably competent fire engineer and in relation to the shortcomings of the draft Existing Fire Safety Strategy. We recognise that the document produced by Ms Cooney was no more than a draft, but even a draft can be expected to cover the necessary ground, identify missing information and provide a basis for the eventual completion of the finished document. Moreover, the document contained a number of material errors and omissions that should never have been made by a competent fire engineer undertaking this sort of work, such as the assumption that there was a firefighting and evacuation lift.⁶³²⁶³² As summarised in Lane, Phase 2 Report {BLARP20000017/157} section 5.7. Errors of that kind should have been identified by any competently conducted peer review, but in this case they were not.

¶54.43 We accept Dr Lane's opinion that the information available to Ms Cooney was so limited that she should either have refused to produce a draft until further information had become available or have included an express warning that no reliance could be placed upon the document until further work had been done.⁶³³⁶³³ Lane {Day61/83:24}-{Day61/85:7}. Much of the missing information could have been obtained and many of her assumptions tested by the simple expedient of carrying out the site visit which had been provided for in the fee proposal. In our view those were very significant omissions, not least because they deprived Exova of a proper understanding of the means of escape from the tower.

¶54.44 Given the shortcomings in the draft Existing Fire Safety Strategy, we doubt whether Ms Cooney properly understood the full extent of her task. Although the fee proposal stated that the purpose of the Existing Fire Safety Strategy was to inform the fire safety risk assessment and the fire risk management plan, her understanding was that it was only one of a number of documents that would be used for that purpose.⁶³⁴⁶³⁴ Cooney {Day14/60:10}-{Day14/62:2}. Although it is certainly reasonable to have expected the TMO to look at the current fire risk assessment when compiling its fire risk management plan, a fire safety strategy which provided nothing more than a checklist for statutory compliance would be of little use. The TMO required at least some guidance about the condition of the existing building, but the draft Existing Fire Safety Strategy failed to give clear advice of a kind that could affect or influence the management plan, e.g. by drawing attention to respects in which there was a failure to comply with existing requirements (as in the case of the emergency lighting) or where standards that formerly applied had become outdated (as in the location of the dry rising main outlets). Ms Cooney appeared to think that her role was simply to state whether the design of the building as it stood complied with the Building Regulations, not to provide information that would inform the management of fire safety.

¶54.45 Dr Barker's review of the draft was rushed, cursory and superficial and little better than a rubber stamp. She did not follow Exova's peer review system, or if she did, she did not do so thoroughly and with proper care. It was therefore all the more important for her to ensure that someone took the necessary steps to complete the production of the Existing Fire Safety Strategy, but she failed to do so. On 8 August 2012, following his return to work after a period of illness, Mr Ashton asked Dr Barker in terms whether she was taking over the project.⁶³⁵⁶³⁵ {EXO00000668/1}. He received no reply to his question, but Dr Barker seems to have thought that he had assumed responsibility for the work from early September. However, he failed to take any steps to complete the document, apparently in the understanding that she had retained responsibility for it. The confusion thus engendered meant that there was no effective transfer of responsibility for the work, which as a result fell between the cracks and was allowed to remain uncompleted. It amounted to a serious failure in Exova's management processes. That explains why Mr Ashton did not discuss the draft with Mr Sounes, but it does not excuse his failure to carry the work forward. Surprisingly, neither Exova, Studio E or the TMO appears to have asked why the document was no more than a draft or when the completed version would be available. Why that was so remains a mystery.

¶54.46 In our view Exova's work on the Existing Fire Safety Strategy fell well below the standards to be expected of a reasonably competent fire engineer. The Existing Fire Safety Strategy ought to have provided a precise record of the baseline condition of fire safety at Grenfell Tower which could inform the refurbishment fire safety strategy.⁶³⁶⁶³⁶ Cooney {Day14/71:1-19}; {Day14/92:1-10}; Barker {Day15/170:1-25}. The document should have been a critical building block in the establishment of that strategy, since, without understanding the existing condition of the building, it was impossible to understand the full effect of the refurbishment on fire safety.⁶³⁷⁶³⁷ Lane, Phase 2 Report {BLARP20000017/49-50} paragraphs 5.7.3 - 5.7.6. However, Exova's work on the Existing Fire Safety Strategy was poor and incomplete. The document failed to record the condition of the building in its existing state and did not provide a reliable baseline for the creation of a fire safety strategy for the refurbishment.

Cate Cooney's email of 17 August 2012

¶54.47 In addition to producing the Existing Fire Safety Strategy Cate Cooney was also involved in some of the other fire safety aspects of the refurbishment. On 16 August 2012, having received her email attaching the draft Existing Fire Safety Strategy, Bruce Sounes asked her to advise on the introduction of residential units on the mezzanine floor of the building for the purposes of a submission to RBKC's planning department the following week.⁶³⁸⁶³⁸ {SEA00000043}. Later that morning Ms Cooney sent Andrew Martyn, a senior consultant at Exova,⁶³⁹⁶³⁹ Martyn {EXO00001577/2} page 2, paragraph 3.2. an email to which she attached plans showing the layout of the new flats. Having mentioned that she had spoken to Bruce Sounes, she said:

"We have just sent through the existing fire strategy for it, basically 1970s 24 storey residential tower with non-residential use to first 4 floors. They are now adding additional levels which merges uses around a single stair. Not great. Basically I have told him we can massage the proposal to something acceptable, with separation, lobbies etc but that there are approval risks to the project on the ff shaft / MOE front. James has been to site and given some advice, but I don't know what he's said, but it would appear not much. They are making an existing crap condition worse so it's a matter of working the worse bits out and making the new stuff work. No sprinklers wanted. LABC building control Kensington and Chelsea – do we have any contacts there?"⁶⁴⁰⁶⁴⁰ {EXO00001279}.

¶54.48 This email gained some prominence during the hearings because of its blunt and colourful language. However, the message speaks for itself: first, the existing condition of the building raised concerns about fire safety; second, the proposed refurbishment would increase those concerns; and third, the proposals could be altered to make them satisfactory from the perspective of building control but there would remain a risk that approval would be refused because of dissatisfaction with the fire-fighting shaft and the means of escape.

¶54.49 Ms Cooney denied that her use of the word "massage" had been intended to mean anything more than "change". She emphatically denied any suggestion that she had used the word in the sense of manipulation or sleight of hand in order to get the designs past building control.⁶⁴¹⁶⁴¹ Cooney {Day14/207:25}-{Day14/209:16}. She said that her intention was to propose substantive changes to the design to make it more acceptable to building control in accordance with the Building Regulations.⁶⁴²⁶⁴² Cooney {EXO00001590/7} page 7, paragraph 5.3; Cooney {Day14/208:17}-{Day14/209:6}. We accept her evidence about that.

¶54.50 The key to understanding the substantive points being made in the message is the reference to adding additional levels which merge uses around a single stair. That is what Ms Cooney was referring to when she used the expression "making an existing crap condition worse". The existing arrangements, under which the occupants from areas in different uses were required to use the same stair as an escape route, was not considered to be consistent with modern guidance (in her words "not ideally something we would be looking for") and would be made worse by the addition of additional flats at the lower levels. Her proposal was to introduce "new measures" to reduce the risk of building control's refusing approval.⁶⁴³⁶⁴³ Cooney {Day14/209:18}-{Day14/211:8}; {Day14/225:9-17}.

¶54.51 Ms Cooney did not recall her conversation with Mr Sounes about this email.⁶⁴⁴⁶⁴⁴ Cooney {Day14/206:14-18}. Although he did recall a discussion with Ms Cooney about different escape routes, he was clear that the email reflected a level of concern within Exova of which he had previously been unaware and which had not been disclosed in Exova's subsequent report to him.⁶⁴⁵⁶⁴⁵ Sounes {Day8/5:17}-{Day8/7-17}. We accept Mr Sounes' evidence on this point and we doubt that Ms Cooney ever conveyed to him the full extent of her concerns, including her view that the refurbishment was "making a crap condition worse". There is no record of those concerns having been expressed by Ms Cooney to Studio E in the plain terms in which they were couched in her email to Mr Martyn (or indeed at all). Nor do they appear to have been communicated to Dr Barker. Perhaps most importantly, there is no record of their having been expressed to Exova's client, the TMO. Given the seriousness of the concerns we would have expected Exova to have communicated them directly to the TMO and in our view, in failing to do so it fell short of the standard to be expected of a reasonably competent fire engineer.

¶54.52 Although Ms Cooney's message concerned the refurbishment, which was Mr Ashton's responsibility rather than hers, it was not copied to Mr Ashton, who did not see it at the time. However, he said that even if he had seen it, it would not have caused him any particular concern.⁶⁴⁶⁶⁴⁶ Ashton {Day17/8:17-19}. He told us that he had told the design team fairly forcefully at his first meeting with them (possibly on 6 September 2012) that Studio E's proposals would not receive building control approval and that serious work was required to ensure that the scheme was accepted.⁶⁴⁷⁶⁴⁷ Ashton {Day17/5:17}-{Day17/9:12}. Although Mr Sounes could not recall what Mr Ashton had said, he accepted that he might well have said something to that effect, since it was consistent with what they had understood to be the problem in a building with a single stair and limited smoke exhaust to the lobbies.⁶⁴⁸⁶⁴⁸ Sounes {Day21/124:10}-{Day21/125:20}.

¶54.53 Dr Lane criticised Ms Cooney for failing to draw her concerns to the attention of those responsible for the building.⁶⁴⁹⁶⁴⁹ Lane {Day61/125:18-24}; Lane, Phase 2 Report {BLARP20000017/337} paragraph 14.1.30. In her view the casual tone of the message demonstrated a failure to recognise that the primary goal of a fire engineer is to protect people's lives by means of the fire safety design solutions for which they are responsible⁶⁵⁰⁶⁵⁰ Lane, Phase 2 Report {BLARP20000017/337} paragraph 14.1.29. and in her oral evidence, she emphasised the "massive responsibility" that fire engineers have to protect people. Dr Lane thought that this email indicated a culture within the Exova team of "making things work and getting things through",⁶⁵¹⁶⁵¹ Lane, Phase 2 Report {BLARP20000017/337} paragraph 14.1.27. similar to that which she had experienced elsewhere in the construction industry. It is an approach which concentrates more on obtaining building control approval than on ensuring people's safety.⁶⁵²⁶⁵² Lane {Day61/126:1-23}. We agree and have noticed many examples of that attitude displayed by others involved in the refurbishment.

Ms Cooney's email of 10 September 2012

¶54.54 On 10 September 2012, following her return from holiday, Ms Cooney sent Mr Ashton an email in which she gave him her thoughts on the problems associated with the additional flats proposed for Grenfell Tower. After setting out how the design could be changed to make the building safer, she said:

"The existing ventilation system is questionable and the overall scheme theoretically makes the existing conditions worse by adding the additional risk of 2 No extra residential floors to the building. It is proposed to upgrade the ventilation system, but the standard it will achieve is unknown."⁶⁵³⁶⁵³ {EXO00000388}.

¶Ms Cooney finished by stating again that she saw a "significant approvals risk with the current proposals".

¶54.55 This message was a more detailed version of her email to Andrew Martyn of 17 August 2012. It does not appear that Mr Ashton responded in substance to it, although he did acknowledge receipt.⁶⁵⁴⁶⁵⁴ {EXO00000667}. Mr Ashton said that it had not been necessary for him to discuss the message with Ms Cooney because it "was pretty comprehensive".⁶⁵⁵⁶⁵⁵ Ashton {Day17/6:11-14}. It did not prompt him to discuss the draft Existing Fire Safety Strategy with her or to ask her to complete it.⁶⁵⁶⁶⁵⁶ Ashton {Day18/16:7-25}. Ms Cooney could not recall ever having discussed the draft Existing Fire Safety Strategy with Mr Ashton in detail so that he could use it as a baseline for the Outline Fire Safety Strategy.⁶⁵⁷⁶⁵⁷ Cooney {Day14/218:19}-{Day14/219:1}.

The Design Note

¶54.56 While Exova was working on the draft Existing Fire Safety Strategy communications about the Outline Fire Safety Strategy for the refurbishment had continued. On 7 August 2012 Mr Sounes contacted Dr Barker to tell her that he would be submitting a Stage C type document to the client by the end of the week or during the following week. He wanted to know whether she had any comments or reservations about the scheme and whether the strategy for fire safety was achievable.⁶⁵⁸⁶⁵⁸ {SEA00005595/1}. He also said that he wanted "… any implications of the layout and external works is understood by the rest of the design team…" Mr Sounes, Dr Barker and Mr Ashton understood the phrase "external works" to relate to the landscaping. See Sounes {Day7/213:10-11}; Ashton {Day17/14:10}-{Day17/15:2}; Barker {Day15/58:2-30}.

¶54.57 Two weeks later, on 28 August 2012, Mr Sounes chased Ms Cooney for a mark-up of the plans and expressed his concern that the fire safety strategy for the proposed design was still embryonic.⁶⁵⁹⁶⁵⁹ {SEA00000058}. See also Sounes {Day8/12:22-25}-{Day8/13:1-2}. Later, on 12 September 2012, a document describing itself as a Design Note⁶⁶⁰⁶⁶⁰ {TMO10001562}. was prepared by Mr Ashton and reviewed by Sean McEleney. It was produced two days after a meeting between Mr Ashton and Mr Sounes on 10 September 2012 and purported to provide an outline fire safety strategy for the refurbishment. Mr Ashton explained that it was intended to be a series of "headlines"⁶⁶¹⁶⁶¹ Ashton {Day16/164:20}-{Day16/165:5}. for achieving a satisfactory fire safety strategy for the refurbished building to assist Studio E in developing the design⁶⁶²⁶⁶² Ashton {EXO00001621/7} page 7, paragraph 4.2. and also to put in writing what had been discussed at the meeting. Although not intended to be a RIBA Stage C report, the Design Note was issued for Stage C⁶⁶³⁶⁶³ {Day16/165:7-12}. and was included in the formal reporting package for Stage C on 31 October 2012.⁶⁶⁴⁶⁶⁴ {SEA00006429}.

¶54.58 Mr Ashton did not visit the tower, either before drafting the Design Note or afterwards, despite having been told by Bruce Sounes in May 2012 that a site visit was probably essential⁶⁶⁵⁶⁶⁵ {EXO00000685}. and despite the view that he had himself expressed at the time that it would be better to visit the building before giving the necessary advice.⁶⁶⁶⁶⁶⁶ {EXO00000685}. When he gave evidence he conceded that a visit would have been desirable,⁶⁶⁷⁶⁶⁷ Ashton {Day16/169:7}. explaining that he failed to make one because he had "other priorities."⁶⁶⁸⁶⁶⁸ Ashton {Day16/168:8-25}. He therefore became familiar with the tower only from the drawings provided by Studio E.⁶⁶⁹⁶⁶⁹ Ashton {Day16/168:25}-{Day16/169:1-2}. However, he did not have any notes from James Lee's visit and did not look at Mr Lee's photographs.⁶⁷⁰⁶⁷⁰ Ashton {Day16/170:7-14}. He had no conversations with Mr Lee about the layout of the building⁶⁷¹⁶⁷¹ Ashton {Day16/171:2-5}. or about the plans to overclad it.⁶⁷²⁶⁷² Ashton {Day16/172:3-7}. There appears to have been no formal handover of the work from Mr Lee to Mr Ashton and Mr Ashton made no enquiries of the TMO building maintenance team before carrying out his work.⁶⁷³⁶⁷³ Ashton {Day16/172:16-18}. If he had done so, he might have gained some important information, for example, that the smoke control system had ceased to function and that the lifts were not in fact firefighting lifts. He might also have obtained a better overall understanding of the condition of the building.

¶54.59 The Design Note itself did not identify the information that Mr Ashton had relied on for its production, but we know that he had access to the draft Existing Fire Safety Strategy,⁶⁷⁴⁶⁷⁴ {EXO00000413}. some marked up General Arrangement plans⁶⁷⁵⁶⁷⁵ Attached to the email of 10 April 12 {EXO00000468} were the following drawings: SK003-Rev00 - Existing Sections + Elevations {TMO00830016} (10.4.12); SK001-Rev01 - Existing Floor Plans (10.4.12) {TMO00831044}; SK002-Rev00 Deck 0 & Deck 1 Layout Proposals 10.4.12 {TMO00831044}. and the 2010 fire risk assessment,⁶⁷⁶⁶⁷⁶ {TMO10017402}. which he considered to be enough for his purposes.⁶⁷⁷⁶⁷⁷ Ashton {Day16/173:4-6}. He also had access to the planning drawings available on a File Transfer Protocol (FTP) site to which Mr Sounes had sent him a link,⁶⁷⁸⁶⁷⁸ {EXO00000716}. but he did not make use of them.⁶⁷⁹⁶⁷⁹ Email from Terence Ashton to Adrian Jess dated 19 November 2012{EXO00000601/3} "I haven't logged on to this FTP site before…"; Ashton {Day17/65:6} "I didn't access the FTP site anyway."

¶54.60 Of the five functional requirements relating to fire safety in Schedule 1 of the Building Regulations 2010, the Design Note dealt only with Requirements B1 (Means of Warning and Escape) and B5 (Access and Facilities for the Fire Service). Mr Ashton explained that he concentrated on those two requirements because the design team wanted answers on them immediately and the other requirements were not as pressing.⁶⁸⁰⁶⁸⁰ Ashton {Day16/174:13-21}.

¶54.61 The Design Note contained no analysis of Requirement B4 and no reference to the cladding. Mr Ashton explained that, although he had seen a reference in Mr Sounes' email of 3 May 2012 to overcladding the tower,⁶⁸¹⁶⁸¹ {EXO00000474}. he had not at that stage seen any specific proposals that he could comment on,⁶⁸²⁶⁸² Ashton {EXO00001621/7} page 7, paragraph 4.3. nor had he discussed the cladding build-up with any of the design team. Although cladding is mentioned in very general terms in the minutes of a Project Meeting on 6 September 2012 which he attended,⁶⁸³⁶⁸³ {ART00000404/4}. Mr Ashton did not remember anything of the discussion, suggesting that he might have left early.⁶⁸⁴⁶⁸⁴ Ashton {Day16/178:4-8}. Mr Sounes thought that, during his meeting with Mr Ashton on 10 September 2012, there had been elevation drawings on the table showing the proposed cladding and was almost sure they had discussed it,⁶⁸⁵⁶⁸⁵ Sounes {Day 8/48:23}-{Day8/49:6}. but Mr Ashton did not recall having seen any drawings and said that they had certainly not discussed any. His recollection was that their discussions focused on the means of escape.⁶⁸⁶⁶⁸⁶ Ashton {Day16/154:8-14}. On balance, given that the design of the cladding system was in its infancy at that stage, we think it unlikely that Mr Sounes and Mr Ashton discussed it in any detail before the Design Note was produced. That is consistent with Mr Sounes' evidence that the contents of the Design Note reflected his conversations with Exova.⁶⁸⁷⁶⁸⁷ Sounes {SEA00014273/61} page 61, paragraph 128.5.

¶54.62 The absence of an analysis of Requirement B4 did not trouble Mr Sounes, because at that stage his priority was understanding the scope of the proposed changes to the structure of the building and ensuring that the contents of the planning application were both feasible and complied with the Building Regulations.⁶⁸⁸⁶⁸⁸ Sounes {Day8/21:6-19}. He also said that the Design Note had given him reason to believe that means of escape (Requirement B1) and access facilities for the fire service (Requirement B5) were the most significant matters that needed to be dealt with at that point.⁶⁸⁹⁶⁸⁹ Sounes {Day8/21:20}-{Day8/23:5}; Sounes {SEA00014273/61} page 61, paragraph 128.5. His discussions with Exova and the contents of the Design Note had given him a degree of confidence.⁶⁹⁰⁶⁹⁰ Sounes {Day8/24:14-15}.

¶54.63 The Design Note indicated that the existing smoke control system serving the lobbies did not comply with current guidance and therefore needed to be refurbished or modified,⁶⁹¹⁶⁹¹ {TMO10001562/2} under Existing Parts. but it did not describe the condition of the system. That is surprising, given that the day before the document was produced Mr Ashton had been told that it was not working properly.⁶⁹²⁶⁹² Email from Paul Dunkerton (KCTMO) to Terence Ashton, forwarding an email from Janice Wray {EXO00000220} which attaches KCTMO's investigation into a fire that occurred at Grenfell Tower on 30 April 2010 {TMO10001785}. His bland description of the state of the smoke control system can be contrasted with the more strongly worded email he received from Cate Cooney on 10 September 2012.⁶⁹³⁶⁹³ {EXO00000388}. Nowhere in the Design Note did he spell out that there was a significant risk that the proposals would not receive building control approval.

¶54.64 The Design Note also pointed out that, as stairs serving residential accommodation should not also serve non-residential accommodation, it might be necessary to provide sprinkler or water mist systems to the boxing club and office suite.⁶⁹⁴⁶⁹⁴ {TMO10001562/2}; Ashton {EXO00001621/8} page 8, paragraph 4.4. It is also listed as a potential solution to the mixing of non-residential stairs with the open base to the firefighting stair in Cate Cooney's email of 10 September 2012 {EXO00000388}. Yet in no version of the Outline Fire Safety Strategy did Mr Ashton advise that sprinklers might be necessary and there is no record of sprinklers having been discussed in design team meetings.⁶⁹⁵⁶⁹⁵ Ashton {Day18/143:13-15}; Lane, Phase 2 Report {BLARP20000017/171} paragraph 6.3.16.

¶54.65 Dr Lane was critical of the Design Note on the grounds that it did not provide the necessary information in sufficient detail to enable the design to be developed to RIBA Stage C with respect to fire safety.⁶⁹⁶⁶⁹⁶ Lane, Phase 2 Report {BLARP20000017/170} paragraph 6.3.9. It appeared to have been produced in haste in order to meet a project deadline⁶⁹⁷⁶⁹⁷ Lane, Phase 2 Report {BLARP20000017/174} paragraph 6.3.27. and dealt only with functional requirements B1 and B5. It therefore failed to provide adequate guidance to the design team on all those aspects of fire safety that needed to be considered in connection with the refurbishment. In our view all those criticisms are well founded.

Issue 1 of the Outline Fire Safety Strategy: 31 October 2012

¶54.66 Issue 1 of the Outline Fire Safety Strategy⁶⁹⁸⁶⁹⁸ {EXO00000519}. was prepared by Mr Ashton and reviewed by Mr McEleney. It was addressed to Studio E. Although it does not identify the RIBA Stage for which it had been prepared, Mr Ashton said that it was appropriate for Stage C.⁶⁹⁹⁶⁹⁹ Ashton {Day17/23:4-16}. It was issued on 31 October 2012, too late to be incorporated into the formal reporting package for that stage of the works.⁷⁰⁰⁷⁰⁰ Studio E's Stage C Report was issued on 31 October 2012 {ART00008396}; Max Fordham's Stage C report was issued on 10 October 2012 {MAX00000636}. Mr Ashton said that he had not been aware that the report needed to be issued at the same time as the other RIBA Stage C reports.⁷⁰¹⁷⁰¹ Ashton {Day17/24:4-19}.

¶54.67 Nowhere in Issue 1 of the Outline Fire Safety Strategy did Exova state that the refurbishment included overcladding of the building.⁷⁰²⁷⁰² The report states that it is based on discussions with the design team and drawings (numbers 1279 RE 110 05, 1279 RE112 04, 1279 RE113 04 and 1279 RE114 03) produced by Studio E LLP {EXO00000856}; {EXO00000858}; {EXO00000860}; {EXO00000861}. That was consistent with the description of the refurbishment in the introduction to the report, which omitted any reference to the overcladding, despite the fact that Mr Ashton was well aware by that time that it constituted an important feature of the works. Although he sought to justify that omission by saying that there had been nothing in the report relating to overcladding (as indeed was the case), he accepted that something of that significance ought to have been included in the description of the refurbishment.⁷⁰³⁷⁰³ Ashton {Day17/101:3-20}.

¶54.68 The only reference in the document to functional requirement B4 was in section 3.1.4,⁷⁰⁴⁷⁰⁴ {EXO00000519/8}. which read:

"Compliance with B4 (External fire spread) It is considered that the proposed changes will have no adverse effect on the building in relation to external fire spread but this will be confirmed by an analysis in a future issue of this report."

¶54.69 Moreover, although section 3.1.3 dealt with functional requirement B3 (unseen spread of fire in concealed spaces), it was confined to the internal structure and compartmentation generally. It did not deal with compartmentation and concealed spaces within the external wall.⁷⁰⁵⁷⁰⁵ {EXO00000519/7-8}. The document contained no reference to the application of requirement B3 to the external wall, such as could be found in section 9 of the current edition of Approved Document B in relation to the requirement for cavity barriers.

¶54.70 Mr Ashton said that the documents on which the report had been based had not provided any information about the cladding⁷⁰⁶⁷⁰⁶ Ashton {EXO00001621/10} page 10, paragraph 4.9 (D). and that he had not been given any details on which he could comment.⁷⁰⁷⁷⁰⁷ Ashton {EXO00001621/9} page 9, paragraph 4.9; Ashton {Day17/39:17}-{Day17/41:8}. He had expected that information to be provided by Studio E and had assumed that matters relating to requirement B4 would be discussed at a meeting.⁷⁰⁸⁷⁰⁸ Ashton {Day17/49:8-22}. When asked why he had not made it clear in the report that he had insufficient information to make an assessment in relation to requirement B4, he said simply, "That's not the way we chose to do it. The truth of the matter is that we didn't have any details that we could comment on."⁷⁰⁹⁷⁰⁹ Ashton {Day17/41:4}.

¶54.71 That was not entirely correct. Although the general arrangement drawings listed in the introduction to the Outline Fire Safety Strategy⁷¹⁰⁷¹⁰ {EXO00000519/4}. The drawings can be found at: Proposed Floor Plans {EXO00000856}; Proposed Mezz Plan {EXO00000858}; Proposed Walkway Plan {EXO00000860}; Proposed Walkway+1 Plan {EXO00000861}. contain no sections or elevations of the tower (and therefore no details of the external wall arrangements), Mr Ashton already had some information about the external wall build-up, having received a draft of potential work packages⁷¹¹⁷¹¹ {SEA00006395}. from Adrian Jess of Studio E on 23 October 2012⁷¹²⁷¹² {SEA00006394}. for the purposes of a design team workshop to be held on Thursday 25 October 2012. The section entitled "Architectural Strategy" referred to overcladding comprising insulation with zinc rainscreen,⁷¹³⁷¹³ {SEA00006395}. but it is unlikely that Mr Ashton looked at that document, since it did not have any obvious relevance to fire safety and he had not been asked to do so.⁷¹⁴⁷¹⁴ Ashton {Day17/30:1}-{Day17/32:9}.

¶54.72 The statement in Issue 1 of the Outline Fire Safety Strategy relating to compliance with functional requirement B4 led Mr Sounes to understand that it was too soon for Exova to comment on the structure of the external wall, but he took it as confirmation that Exova had no immediate concern about the proposals.⁷¹⁵⁷¹⁵ Sounes {Day8/52:9-11}; See also Sounes {SEA00014273/73} page 73, paragraph 149. Mr Ashton, however, did not realise that.⁷¹⁶⁷¹⁶ Ashton {Day17/47:25}-{Day17/48:4}.

¶54.73 Studio E produced its RIBA Stage C report on 31 October 2012. It was sent to the TMO by a link in an email sent at 11.37 which was copied to the design professionals, including Mr Ashton.⁷¹⁷⁷¹⁷ {ART00008396}. Just under five hours later, at 16.21, Margaret Treanor, an administrative assistant at Exova, sent Issue 1 of the Outline Fire Safety Strategy to Adrian Jess at Studio E.⁷¹⁸⁷¹⁸ {EXO00000518}. There may have been a brief interlude, therefore, in which Mr Ashton could have read the Stage C report before he released the Outline Fire Safety Strategy, but he did not read it then or later, because the email to which it had been attached had not been addressed to him and he had not specifically been asked to read it. It was not his practice to look at Stage C or Stage D reports unless specifically asked to do so.⁷¹⁹⁷¹⁹ Ashton {Day17/97:8}-{Day17/98:4}, {Day17/98:17-19}. Dr Pearson's evidence was also that architects would usually provide them with Stage C or Stage D reports voluntarily. Pearson {Day19/110:16-25}.

¶54.74 If Mr Ashton had read the Stage C report carefully, he would have seen that the tower was to be overclad,⁷²⁰⁷²⁰ {SEA00006429/27}. with various options being considered for the rainscreen, including zinc⁷²¹⁷²¹ {SEA00006429/28}; {SEA00006429/31}; {SEA00006429/32}. and aluminium.⁷²²⁷²² {SEA00006429/32}. He would also have seen that Celotex FR5000 was proposed as insulation in the external wall.⁷²³⁷²³ {SEA00006429/82-83}. Mr Ashton repeatedly said that he had not been told what insulation or rainscreen was being used on the tower.⁷²⁴⁷²⁴ Ashton {Day17/92:2-14}; {Day17/95:19-20}.

Further information provided to Mr Ashton in November 2012

¶54.75 On 16 November 2012 Adrian Jess of Studio E sent Mr Ashton a link to Studio E's then current drawings on an FTP site.⁷²⁵⁷²⁵ {SEA00006666}. Mr Ashton had not previously used the site and asked for assistance.⁷²⁶⁷²⁶ {EXO00000601/3}. However, although Mr Jess sent him a new link to the site, he did not visit it and so did not see the drawings it contained. Nor did he ask to be given the drawings in some other way.⁷²⁷⁷²⁷ Ashton {Day17/63:17-19}; {Day17/64:15-25}. Mr Ashton's lack of interest in the information being made available to him is regrettable to say the least, but it is not clear which drawings were available on the FTP site at that time or whether they contained any information about the external wall.⁷²⁸⁷²⁸ Proposed Walkway +1 Floor Plan, annotated {SEA00006728}; Proposed Mezzanine Floor Plans, annotated {SEA00006727}, attached to email {SEA00006726}.

¶54.76 In both her written and oral evidence Dr Lane was critical of Issue 1 of the Outline Fire Safety Strategy, not just for failing to record the fact that the project included the overcladding of the entire building but for expressing the view, albeit subject to confirmation in due course, that the work would have no adverse effect on the building in relation to external fire spread.⁷²⁹⁷²⁹ Lane {Day61/168:16-21}; Lane, Phase 2 Report {BLARP20000017/188}, paragraph 6.5.10. The purpose of obtaining an Outline Fire Safety Strategy was to provide the design team with the information they needed to ensure that when the refurbishment had been completed the building would be safe for occupation. Dr Lane said that in a document of this kind she would expect a reasonably competent fire engineer to set out, as a bare minimum, the statutory guidance relating to insulation, cavity barriers, and the external surface, with references to the relevant sections of Approved Document B.⁷³⁰⁷³⁰ Lane {Day61/168:16-21}; {Day61/169:18-25}; {Day61/170:5-8}; {Day61/170:18-20}. That would involve making clear the performance required of each of the separate elements of the external wall.⁷³¹⁷³¹ Lane {Day61/169:18}-{Day61/170:20}. She agreed that Exova could properly have made it clear that it had no information about the proposed cladding and would consider that at a later stage, but considered that to express even a provisional opinion without the benefit of any information about the cladding was unacceptable.⁷³²⁷³² Lane, Phase 2 Report {BLARP20000017/187-188} paragraphs 6.5.9-6.5.12.

¶54.77 Neither Mr Ashton nor anyone else at Exova had any information about the proposed cladding and no attempt had therefore been made to analyse the proposals for the external wall of the building. Exova therefore had no basis for expressing an opinion, even of a provisional nature, that the proposed work would have no adverse effect on the building in relation to external fire spread. Such a statement was bound to lead Studio E and the TMO to assume that, unless it was later withdrawn or modified, they could be confident that the building would comply with functional requirement B4 and be safe for occupation. Dr Lane considered that the inclusion of that statement fell short of the standards to be expected of a competent fire engineer, a view with which we agree.

Liaison with building control 2012–2013

¶54.78 Following the production of Issue 1 of the Outline Fire Safety Strategy in October 2012, Mr Ashton took the lead in dealing with building control in relation to fire safety aspects of the Grenfell Tower refurbishment. He sent Issue 1 of the Outline Fire Safety Strategy directly to John Allen on 31 October 2012.⁷³³⁷³³ {SEA00006443}. He also organised a meeting at Kensington Town Hall on 6 November 2012 with Mr Jess and John Allen and Dave Gammon, both of RBKC building control, to introduce the scheme to them, to gauge their response and to discuss the fire strategy.⁷³⁴⁷³⁴ Terence Ashton's notes of this meeting are at {EXO00001371}; Adrian Jess's notes of the meeting are at {SEA00006526}. He said that RBKC building control could be difficult to deal with, particularly when presented with something that did not comply exactly with official guidance.⁷³⁵⁷³⁵ Ashton {Day17/66:9}-{Day17/67:19}. He told Bruce Sounes that they set their own standards, by which he meant that they were sticklers for compliance.⁷³⁶⁷³⁶ {ART00000385}.

¶54.79 Mr Ashton said that neither functional requirement B4 nor the overcladding of the tower was discussed during the meeting because its purpose had been to discuss Issue 1 of the Outline Fire Safety Strategy report.⁷³⁷⁷³⁷ Ashton {Day17/70:7-18}. John Allen said that he did not believe that cladding had been referred to during the meeting, although he could not recall the meeting at all. Allen {Day47/175:4-11}. He said he would have expected Studio E to have put overcladding on the agenda if it had needed to be discussed; he did not think it his responsibility to do that.⁷³⁸⁷³⁸ Ashton {Day17/70:14}-{Day17/71:7}; {Day17/73:13-16}. According to Mr Sounes, a meeting of that kind would normally begin with a brief description of the project, which would inevitably have included a description of the cladding. However, given the absence from Mr Jess's detailed notes of any reference to the overcladding,⁷³⁹⁷³⁹ {SEA00006526}. we think it unlikely that it was discussed or even mentioned in a way that could have been expected to lodge in Mr Ashton's mind.

¶54.80 Mr Ashton met building control again for the last time on 17 September 2013 to discuss the fire strategy.⁷⁴⁰⁷⁴⁰ {EXO00000693/5}. He agreed that he would normally have expected to have had more meetings with them⁷⁴¹⁷⁴¹ Ashton {Day17/182:13-19}. and indeed the Fee Proposal allowed for one meeting at Stage C and two meetings at Stage D or E,⁷⁴²⁷⁴² {EXO00001349/2}; {EXO00001349/3}. It was also envisaged that at Stage F work would include, when appropriate, discussion with "the regulatory approvers", including attendance at up to one meeting in London. but he had expected them to be arranged only if Studio E asked for them.⁷⁴³⁷⁴³ Ashton {Day17/182:20-24}. Again, there is no evidence that the overcladding of the tower was discussed at that meeting.⁷⁴⁴⁷⁴⁴ Sounes {Day21/135:1}-{Day21/136:9}. Mr Ashton said that he had never discussed with anyone from building control whether the cladding proposals complied with the guidance in Approved Document B⁷⁴⁵⁷⁴⁵ Ashton {Day17/181:9-12}. and there is no written record of any such discussion having taken place.

Issue 2 of the Outline Fire Safety Strategy: 24 October 2013

¶54.81 Issue 2 of the Outline Fire Safety Strategy was dated 24 October 2013.⁷⁴⁶⁷⁴⁶ {EXO00000430}. It was written by Mr Ashton and reviewed by Dr Tony Pearson, a senior consultant⁷⁴⁷⁷⁴⁷ According to Dr Pearson a senior consultant was the minimum grade for reviewing other people's work, for managing a more complicated project or for leading negotiations with building control. Pearson {Day19/3:16-19}. although junior to Mr Ashton at Exova. It was produced following the meeting with building control on 17 September 2013, after which alterations had been made to some of the drawings on which the previous report had been based.⁷⁴⁸⁷⁴⁸ Ashton {Day17/116:11-18}; {EXO00000390}. The altered drawings can be found at {EXO00000961}, {EXO00000962}, {EXO00000980}. Issue 2 of the Outline Fire Safety Strategy did not identify the RIBA Stage for which it had been written. According to Mr Ashton, it could have been intended for use at Stage D, although unknown to him Studio E had already produced its Stage D report in August 2013.⁷⁴⁹⁷⁴⁹ Ashton {Day17/99:17-18}.

¶54.82 Studio E's Stage D report had included Issue One of Exova's Outline Fire Safety Strategy at Appendix D,⁷⁵⁰⁷⁵⁰ {SEA00008054/78}. a fact of which Mr Ashton was also unaware.⁷⁵¹⁷⁵¹ Ashton {Day17/97:8-11}. Since he had not read the Stage D report, (or, for that matter, the Stage C report),⁷⁵²⁷⁵² Ashton {Day17/100:25}; Stage C report {SEA00006429}. it is no surprise that neither of the reports was referred to in Issue 2 of the Outline Fire Safety Strategy. If Mr Ashton had read the Stage D report, he would have seen the reference to the zinc composite rainscreen proposed for the upper levels,⁷⁵³⁷⁵³ {SEA00008054/22}; {SEA00008054/29}. images of cladding⁷⁵⁴⁷⁵⁴ {SEA00008054/26}. and references to Celotex FR5000 as the proposed insulation.⁷⁵⁵⁷⁵⁵ {SEA00008054/29}. By that time, however, Studio E was working to the Employer's Requirements – Stage E,⁷⁵⁶⁷⁵⁶ Sounes {Day8/67:25}; Sounes {SEA00014273/105} page 105, paragraph 241. so Mr Ashton was once again out of step with the other design professionals on the project.

¶54.83 When reviewing Issue 2 of the Outline Fire Safety Strategy, Dr Pearson had seen only the general arrangement floor plans and the mark-ups on the drawings produced by colleagues at Exova.⁷⁵⁷⁷⁵⁷ Pearson {Day19/109:5-16}. It would have been useful for him to have seen the minutes of the discussions with building control, but they had not been made available to him.⁷⁵⁸⁷⁵⁸ Pearson {Day19/105:13-19}; {Day19/126:21-24}. He had not seen the draft Existing Fire Safety Strategy which ordinarily he would have wanted to see when conducting a review of that kind.⁷⁵⁹⁷⁵⁹ Pearson {Day19/107:3-4}. Dr Pearson did not know what stage of the RIBA process the report was being written for, nor did he know that Studio E had issued its Stage C report in October 2012 and its Stage D report in August 2013.⁷⁶⁰⁷⁶⁰ Pearson {Day19/106:9-24}; {Day19/107:21-25}. We think that he should have known both of those things when carrying out a peer review of the fire safety strategy so that he properly understood the context in which the report was being prepared.

¶54.84 In the introductory section of Issue 2 the description of the refurbishment had been amended,⁷⁶¹⁷⁶¹ {EXO00000430/4} Two additional features were added: "…a new stair providing access to the boxing club at ground storey level;" and "…office accommodation in the mezzanine over the ground storey (mezzanine level)." but it still omitted any reference to the overcladding of the tower. According to Mr Ashton, that was because Exova had still not given any consideration to the cladding.⁷⁶²⁷⁶² Ashton {Day17/100:19-21}. The drawings identified at the end of the introduction were general arrangement drawings and did not show any details of the external wall construction.⁷⁶³⁷⁶³ {EXO00000430/4}. The drawings were: 1279 SEA (08) 100, "Fire Access", 24.10.13 {TMO00828152}; and 1279 SEA (08) 101, "Fire Strategy", 24.10.13 {TMO10040859}. Dr Pearson was not aware at the time that the refurbishment included overcladding,⁷⁶⁴⁷⁶⁴ Pearson {Day19/105:6}; {Day19/122:12-17}. nor did he have any knowledge of the arrangements proposed at the top of the tower,⁷⁶⁵⁷⁶⁵ Pearson {Day19/123:4-14}. all of which may explain why he had no concern about the treatment in the report of functional requirement B4. He assumed that Mr Ashton would carry out an analysis when further information had become available.

¶54.85 In Issue 2 of the report the section dealing with functional requirement B4 (external fire spread) was unchanged and therefore the single sentence at para 3.1.4 remained the only reference to that requirement of the Building Regulations.⁷⁶⁶⁷⁶⁶ "It is considered that the proposed changes will have no adverse effect on the building in relation to external fire spread but this will be confirmed by an analysis in a future issue of this report." Nor did the report contain any express reference to the performance requirements for an external wall. It seems that that was not something which Exova routinely included in a document of that kind.⁷⁶⁷⁷⁶⁷ Ashton {Day17/104:5-7}. Dr Pearson explained that at the time there had been an assumption within Exova that designers knew what the requirements were,⁷⁶⁸⁷⁶⁸ Pearson {Day19/160:8-17}. but with the benefit of hindsight he recognised that that assumption had been misplaced. Similarly, they had assumed that the designers would choose appropriate materials.⁷⁶⁹⁷⁶⁹ Pearson {Day19/171:10-14}.

¶54.86 Mr Ashton said that at the time he had been slightly nonplussed by the fact that the overcladding had not been the subject of any discussion by that late stage in the development of the design,⁷⁷⁰⁷⁷⁰ Ashton {Day17/104:13-16}. yet he also said that he had not thought that there had been a general awareness in the construction industry before the Grenfell Tower fire of the need to look critically at the construction of external walls.⁷⁷¹⁷⁷¹ Ashton {Day 17/104:17}-{Day17/105:7}. That suggests, however, that Mr Ashton was aware that he needed to ensure that this aspect of the project had been, or would be, properly addressed.

¶54.87 Dr Pearson did not discuss section 3.1.4 of the document or requirement B4 with Mr Ashton at the time;⁷⁷²⁷⁷² Pearson {Day19/117:14}. he had absolute faith in Mr Ashton and believed that he would provide all the necessary advice on B4 when appropriate.⁷⁷³⁷⁷³ Pearson {Day19/130:2-21}; {Day19/171:20-22}; {Day19/110:3-9}; {Day19/121:6-13}. However, he was unaware at that time that Mr Ashton had no experience of advising on cladding work on high-rise residential buildings.⁷⁷⁴⁷⁷⁴ Pearson {Day19/125:18-22}.

¶54.88 No changes were made to the section covering functional requirement B3 (internal fire spread)⁷⁷⁵⁷⁷⁵ {EXO00000430/8} section 3.1.3. and therefore there was still no guidance on compliance with Section 9 of Approved Document B and the provision of cavity barriers. Dr Pearson was not concerned that the second issue of the Outline Fire Safety Strategy failed to identify the locations of concealed spaces or places where cavity barriers would be needed because the document was described as an outline rather than a detailed strategy.⁷⁷⁶⁷⁷⁶ Pearson {Day19/114:16-23}. He also failed to notice that the document incorrectly stated that the floors should provide at least 60 minutes' fire resistance, as he took it on trust that that was correct.⁷⁷⁷⁷⁷⁷ Pearson {Day19/111:7-25}.

¶54.89 In the process of conducting his peer review Dr Pearson added a new paragraph to the report drawing attention to the fact that, although the sharing of a means of escape between residential and non-residential accommodation was not endorsed by current statutory guidance, the proposals complied with the Building Regulations because they represented a continuation of the existing principles.⁷⁷⁸⁷⁷⁸ {EXO00000430/6} Section 3.1.1. Mr Ashton said that amendments would usually be discussed before a document was sent out, but that there had been no discussion in this case because they had been under pressure of time.⁷⁷⁹⁷⁷⁹ Ashton, {Day17/175:1-13}. Mr Ashton had asked for the document to be sent out without having read Dr Pearson's amendment and was irritated by it when he did read it,⁷⁸⁰⁷⁸⁰ Ashton {Day17/113:14-20}; {EXO00001444}. Dr Tony Pearson had given Terence Ashton two opportunities to comment on the amendment (at 16.13 and at 16.52) before it was sent out. because he thought that it unnecessarily drew attention to a failure to comply with Approved Document B.⁷⁸¹⁷⁸¹ {EXO00001444}. He had noted the fact that the proposal to share the means of escape did not comply with Approved Document B in the Design Note⁷⁸²⁷⁸² {EXO00000142/2}. and he knew that Ms Cooney had previously expressed concern about merging the stairs serving the boxing club and office with those serving the residential units.⁷⁸³⁷⁸³ {EXO00000388}; Ashton {Day17/114:14-24}. He said that he had already established with building control that there was a mixture of uses and that he was addressing it with appropriate fire safety measures,⁷⁸⁴⁷⁸⁴ Ashton {Day17/114:14-24}. but he did not want to draw attention to it in case they said it was not acceptable.⁷⁸⁵⁷⁸⁵ Ashton {Day17/110:25}-{Day17/111:5}; See also Ashton {EXO00001621/11} page 11, paragraph 4.17. Mr Ashton's view was that it was a matter of emphasis and suggested that he had overreacted to what Dr Pearson had written.⁷⁸⁶⁷⁸⁶ Ashton {Day17/112:19-20}.

¶54.90 Dr Lane considered that the problem to which Dr Pearson's amendment drew attention involved a fundamental breach of the Building Regulations and she considered that Mr Ashton's attitude in hoping that building control would not notice it fell below the standards to be expected of a reasonably competent fire engineer.⁷⁸⁷⁷⁸⁷ Lane, Phase 2 Report {BLARP20000017/99}, paragraphs 4.7.81-4.7.82. In her view, it was important when drafting a fire safety strategy to identify any deviations from the statutory guidance so that the different readers could take account of them when making decisions about the project.⁷⁸⁸⁷⁸⁸ Lane {Day61/207:7-13}. We agree and return to this at a later stage when we consider broader questions about Exova's work on this project.

¶54.91 When Mr Ashton produced Issue 3 of the Outline Fire Safety Strategy in November 2013, he retained the statement that "sharing means of escape between residential and non-residential accommodation is not endorsed by current statutory guidance",⁷⁸⁹⁷⁸⁹ {EXO00001107/6}. but deleted from section 3.1.1 the statement that the proposals represented "a continuation of the existing principles for means of escape in the building and therefore do not create a non-compliance with the requirements of the Building Regulations".⁷⁹⁰⁷⁹⁰ {EXO00001107/6}. Mr Ashton did not seek to discuss that amendment with Dr Pearson⁷⁹¹⁷⁹¹ Pearson {Day19/91:11-15}. and Dr Pearson appears not to have realised at the time that the words in question had been removed.⁷⁹²⁷⁹² Pearson {Day19/93:7-23}.

¶54.92 Studio E sent Issue 2 of the Outline Fire Safety Strategy to building control by email on 25 October 2013.⁷⁹³⁷⁹³ {SEA00000121}. John Allen responded on 11 November 2013,⁷⁹⁴⁷⁹⁴ {RBK00002985}. saying that the information submitted was not adequate to enable an effective consultation to be had with the fire authority. Mr Ashton thought that building control's concerns related to Max Fordham's work in designing the smoke control system,⁷⁹⁵⁷⁹⁵ Ashton {Day17/195:18-20}; See also Ashton {EXO00001621/12} paragraph 5.3. and that it was therefore Max Fordham's responsibility to provide whatever additional information was required.⁷⁹⁶⁷⁹⁶ Ashton {Day17/200:1-4}. There is nothing in the email to suggest that building control considered the proposals to be unacceptable because they failed to address functional requirements B3 and B4.

¶54.93 The very fact that Issue 2 of the Outline Fire Safety Strategy was in substance almost identical to Issue 1 produced a year earlier is itself a ground of criticism. Max Fordham and Studio E had produced their RIBA Stage D reports in August 2013.⁷⁹⁷⁷⁹⁷ {SEA00008054}; {TMO00834924}. Dr Lane said that she would have expected a reasonably competent fire engineer about to produce a fire safety strategy for RIBA Stage E to have asked for the Stage D report for use as a reference guide and to check the sections that were relevant to its work.⁷⁹⁸⁷⁹⁸ Lane {Day61/188:7-13}. In her opinion Mr Ashton's failure to obtain the latest information at that stage of the design process fell short of what could be expected of a reasonably competent fire engineer who could be expected to obtain any information needed to complete its work.⁷⁹⁹⁷⁹⁹ Lane {Day61/188:1-23}. We agree.

¶54.94 Exova's failure to review the statement in relation to functional requirement B4 was again the subject of criticism by Dr Lane, who was critical of its failure to provide the guidance that in her view should have been included in Issue 1. We find it very surprising that no one at Exova recognised that the statement relating to functional requirement B4 had not been properly resolved. Mr Ashton's explanation that he had not been provided with the information he needed in order to deal with it was in our view a poor excuse. We consider that a reasonably competent fire engineer would have realised that the report remained incomplete in an important respect, would have drawn the matter to the attention of its client and would have sought the information needed to complete the report. In failing to do so Exova in the person of Mr Ashton fell below the standards to be expected of a reasonably competent fire engineer.

Correspondence with Studio E before Issue 3

¶54.95 After the production of Issue 2 of the Outline Fire Safety Strategy on 24 October 2013, but before the production of Issue 3 on 7 November 2013, a question was raised by the design team about the performance of the external wall. On 1 November 2013, Tomas Rek of Studio E sent an email to Mr Ashton asking him to confirm that the rainscreen cavity barriers were to have 60 minutes' fire resistance to match that of the compartmentation.⁸⁰⁰⁸⁰⁰ {EXO00000586}. Mr Ashton's response on 4 November 2013 was brief, stating simply that cavity barriers needed to have only 30 minutes' fire resistance.⁸⁰¹⁸⁰¹ {EXO00000586}; Ashton {Day17/124:21}-{Day17/125:3}. Mr Ashton did not check Approved Document B before giving that advice because, he claimed, he had known the answer off the top of his head.⁸⁰²⁸⁰² Ashton {Day17/123:25}-{Day17/124:1-2}. Nor did he consider it necessary to advise Mr Rek of the performance requirements set out in Approved Document B for the external wall or the required locations of cavity barriers.⁸⁰³⁸⁰³ Ashton {Day17/124:8-10}; {Day17/126:21-23}. Although he did not have any details of the rainscreen to which Mr Rek had referred, he did not ask for further information since he assumed that it might be forthcoming in the not too distant future.⁸⁰⁴⁸⁰⁴ Ashton {Day17/120:22-25}. Regrettably, Mr Rek's email did not prompt Mr Ashton, as it should have done,⁸⁰⁵⁸⁰⁵ {EXO00000586}; Lane {Day61/212:7}-{Day61/213:7}. to address the external wall requirements in Issue 3 of the Outline Fire Safety Strategy which was produced within a week of this correspondence.⁸⁰⁶⁸⁰⁶ Ashton {Day17/121:6}-{Day17/122:23}.

Issue 3 of the Outline Fire Safety Strategy: 7 November 2013

¶54.96 Issue 3 of the Outline Fire Safety Strategy was produced on 7 November 2013,⁸⁰⁷⁸⁰⁷ {EXO00001107}. less than two weeks after Issue 2. It had been prepared by Mr Ashton and reviewed by Mr McEleney. The stated reason for the revision was to take into account comments from the design team.⁸⁰⁸⁸⁰⁸ {EXO00001107/2}. See also exchanges between Terence Ashton and the Studio E design team {EXO00001408} and changes to the Fire Strategy marked up in yellow on {EXO00001501}. The document was said to be based upon discussions held with the design team and building control and on unidentified fire access and fire strategy drawings produced by Studio E.⁸⁰⁹⁸⁰⁹ {EXO00001107/4}. Exova did not provide a set of fire strategy drawings to accompany Issue 3. Dr Lane was critical of that omission, and explained that anyone reading the report would need both the detailed information on the drawings and the narrative in the report in order to understand the basis for the fire safety design.⁸¹⁰⁸¹⁰ Lane {Day61/221:10-15}.

¶54.97 Again, Exova failed to specify for which RIBA stage the document had been written. Mr Ashton thought that it was another version of one intended for Stage D, but Mr Sounes said it had related to Stage E.⁸¹¹⁸¹¹ Sounes {Day12/147:19-23}. Mr Ashton had still not seen either the Stage C or Stage D report.⁸¹²⁸¹² Ashton {Day17/128:9-18}.

¶54.98 The introduction to Issue 3 described the refurbishment works and, as in the case of Issues 1 and 2, made no mention of the overcladding.⁸¹³⁸¹³ {EXO00001107/4}. The wording of the section covering B4 (external fire spread) also remained the same.⁸¹⁴⁸¹⁴ {EXO00001107/9} paragraph 3.1.4. Mr Ashton explained that nothing had changed since the previous issue because he still had not been given the details of the external wall.⁸¹⁵⁸¹⁵ Ashton {EXO00001621/12} page 12, paragraph 4.20, "Again, I had still seen no proposals in relation to any cladding, and so the report contains the same statement as before." See also Ashton {Day17/130:7-16}. He said that Exova had been disengaged from the design team for a number of months between Issues 1 and 2 and that the project had "gone a bit cold".⁸¹⁶⁸¹⁶ Ashton {Day17/131:6}-{Day17/132:6}. He had been expecting a discussion, but none had taken place by the time the document had been produced.⁸¹⁷⁸¹⁷ Ashton {Day17/131:6-13}. By contrast, Mr Sounes said he had expected Mr Ashton to ask if he needed any further information to enable him to provide the advice covered by Exova's Fee Proposal, including any necessary drawings, details or specifications.⁸¹⁸⁸¹⁸ Sounes {Day12/150:15-20}. In oral evidence, Mr Ashton accepted that Exova should have pursued Studio E more vigorously for information about the external walls, but he rejected the suggestion that retaining the original wording without any clarification was an abdication of its responsibilities as fire strategy consultant for the project.⁸¹⁹⁸¹⁹ Ashton {Day17/135:8-22}.

¶54.99 In common with Issue 2, Issue 3 did not describe the fire performance materials needed to comply with functional requirement B4, nor did it set out the fire safety standards for the construction of external walls, which, according to Dr Lane, was the minimum Exova should have provided by way of advice.⁸²⁰⁸²⁰ Lane, Phase 2 Report {BLARP20000017/214} paragraphs 6.9.12-6.9.13. See also Lane {Day62/25:22-24}; {Day62/26:12-14}. Accordingly, it did not make it clear that the guidance in paragraph 12.7 of Approved Document B required any insulation product used in the external wall to be of limited combustibility. Mr Ashton explained that omission by saying that he did not include performance requirements as a matter of course in every report.⁸²¹⁸²¹ Ashton {Day17/137:8-18}; {Day17/48:13-17}-{Day17/49:11-14}. He accepted that he had taken no steps before the production of Issue 3 to ascertain whether the cladding would or would not be likely to have an adverse effect on the building in relation to fire spread.⁸²²⁸²² Ashton {Day17/130:25}-{Day17/131:5}.

¶54.100 Similarly, Issue 3 contained no guidance on the need for cavity barriers⁸²³⁸²³ {EXO00001107/8} paragraph 3.1.3. nor any reference to the performance requirements for cavity barriers within external walls as set out in section 9 and paragraph 12.8 of Approved Document B, despite the fact that Tomas Rek had sought guidance on that very matter only days earlier.⁸²⁴⁸²⁴ {EXO00000586}.

¶54.101 Issue 3 of the Outline Fire Safety Strategy also omitted any reference to the crown, but that was because Mr Ashton had never been asked to advise on that part of the structure. He had not seen any drawings of the crown and did not know anything about the arrangements at the top of the building.⁸²⁵⁸²⁵ Ashton {Day17/139:16}-{Day17/140:3}. Nor did it contain any reference to the draft Existing Fire Safety Strategy. Dr Pearson said that if he had been the author of the report he would have included a lengthy summary of the existing strategy,⁸²⁶⁸²⁶ Pearson {Day19/108:1-9}. but Mr Ashton was not aware that the Existing Fire Safety Strategy (even though only in draft form) was intended to be the baseline from which the Outline Fire Safety Strategy was to be developed.⁸²⁷⁸²⁷ Ashton {Day18/11:4-7}.

¶54.102 When addressing the means of escape and functional requirement B1, Mr Ashton advised that the design of the smoke control system would be covered in a separate report by Max Fordham.⁸²⁸⁸²⁸ Note under the heading "SMOKE VENTILATION OF LOBBIES", "(this supply and extract system will be overhauled as part of the improvement to the building services. This is covered in a separate report from Max Fordham.)" {EXO00001107/7} and see also Ashton {Day17/143:12-16}. No performance requirements for the new smoke control system were set out, nor was the role of the system specified. Mr Ashton told us that the performance requirements for smoke ventilation systems serving a common lobby were well known in the industry and certainly would have been well known to Max Fordham, so he did not think it necessary to spell them out.⁸²⁹⁸²⁹ Ashton {Day17/143:17}-{Day17/144:3}.

¶54.103 Issue 3 of the Outline Fire Safety Strategy did state that for the walkway, mezzanine and ground floor levels and in the lobby to the boxing club and community room, automatic opening vents of 0.4m² in area would be provided.⁸³⁰⁸³⁰ {EXO00001107/7}. As Mr Ashton accepted, that did not comply with the guidance in Approved Document B, because the size of the opening vents did not comply with BS5588-5:2004,⁸³¹⁸³¹ Referred to in Diagram 52 of Approved Document B, Note 2 {CLG00000224/116}; See also Lane, Phase 2 Report {BLARP20000017/299}. but it was the best that could be achieved. He did not expressly refer to that shortcoming in the strategy because he had discussed it with building control, which appeared to be happy with it on that basis.⁸³²⁸³² Ashton {Day17/146:5-19}.

¶54.104 Similarly, there was no reference in the section dealing with functional requirement B1 to the fact that the width of the stairs at 1040mm was 60mm less than the 1100mm stated in Approved Document B,⁸³³⁸³³ Approved Document B {CLG00000224/32} section 2.33. although Mr Ashton had been aware of the fact, having advised on the question by email in October 2013.⁸³⁴⁸³⁴ {EXO00000739/1}. In response to a question about the width of the stair, Mr Ashton replied, "If the stair were to be used as access for fire-fighters it would have to be 1100mm between walls." See also Ashton {Day17/147:16-20}. He accepted that it could have been added to the narrative discussion in the report, but did not consider that to be necessary, since it was not practicable to alter the stairs, which in his view were perfectly adequate.⁸³⁵⁸³⁵ Ashton {Day17/147:9}-{Day17/149:14}.

¶54.105 The strategy contained no advice that might have assisted the TMO in discharging its duties under the Fire Safety Order or any information about how the active and passive fire safety systems would need to be maintained in order to ensure compliance with the legislation. Nor did it contain any acknowledgement of the fact that the mixed-use nature of the building might result in there being more than one responsible person. Mr Ashton considered that that would be more appropriately addressed in a fire safety management plan.⁸³⁶⁸³⁶ Ashton {Day17/155:16-22}.

¶54.106 Similarly, there was no consideration in the strategy of the means of escape for those in the tower with disabilities because Mr Ashton did not think that the law required designers to consider their position.⁸³⁷⁸³⁷ Ashton {Day17/150:1-11}. He had therefore not asked for information about who was living in the building or who might be living there in the future.⁸³⁸⁸³⁸ Ashton {Day17/153:13-24}. He said that he would not have expected to be given that information by the TMO unless there had been some particular reason to consider it, for example, if the building had been purpose-built for people with disabilities.⁸³⁹⁸³⁹ Ashton {Day17/158:24}-{Day17/159:4}.

¶54.107 Mr Ashton did not review the Fee Proposal before putting the finishing touches to Issue 3 to remind himself of the scope of Exova's instructions; it was not something he did as a matter of routine.⁸⁴⁰⁸⁴⁰ Ashton {Day17/131:20-25}.

¶54.108 Issue 3 was the last version of the Outline Fire Safety Strategy produced by Exova for the Grenfell project⁸⁴¹⁸⁴¹ Ashton {EXO00001621/12} page 12, paragraph 4.18. and represented the culmination of its work on the refurbishment up to and including RIBA Stages D and E.⁸⁴²⁸⁴² Ashton {Day18/165:6-9}. Exova produced nothing commensurate with RIBA Stages E or F.⁸⁴³⁸⁴³ Lane, Phase 2 Report {BLARP20000017/101} paragraph 4.7.104. According to Mr Ashton, that was because Exova had not been novated to Rydon.⁸⁴⁴⁸⁴⁴ Ashton {Day18/166:10-14}. Mr Ashton said that the relatively minor nature of the differences between the three versions of the report reflected changes to the design of the lower four floors.⁸⁴⁵⁸⁴⁵ Ashton {Day18/166:4-9}.

¶54.109 In the event, Exova never did produce a final version of the fire strategy. Mr Ashton did not consider Issue 3 to be the final version⁸⁴⁶⁸⁴⁶ Ashton {Day 17/133:1-3}. and accepted that a detailed fire strategy would have dealt with all the functional requirements from B1 to B5.⁸⁴⁷⁸⁴⁷ Ashton {Day16/101:1-4}. He acknowledged that Issue 3 did not deal with a number of subjects, including an analysis of the external wall in relation to functional requirement B4.⁸⁴⁸⁸⁴⁸ Ashton {Day17/132:16-18}; {Day18/165:18-20}; {Day18/166:1-3}. He said that his intention at the time had been to produce the final version once he had received the necessary information from the design team;⁸⁴⁹⁸⁴⁹ Ashton {Day17/133:1-6}. but he never asked Studio E for that information⁸⁵⁰⁸⁵⁰ Ashton {Day17/133:22-25}. and allowed the matter to drift in the absence of any request from Studio E for a complete analysis.⁸⁵¹⁸⁵¹ Ashton {Day17/48:5-17}. He did not regard completion of the fire safety strategy as a priority and he had a lot of other work on his hands at the time.⁸⁵²⁸⁵² Ashton {Day17/133:11-15}.

¶54.110 Mr Ashton said that building control had never asked for a more detailed fire safety strategy and that Exova had not received any instructions from the TMO to review it.⁸⁵³⁸⁵³ Ashton {Day18/168:4-8}; {Day18/169:5-12}. In retrospect he thought it surprising that he had had no contact with Studio E to discuss a compliance check of the design for the external wall, but he did not consider that it would have been appropriate for him to tell the TMO that further work was required.⁸⁵⁴⁸⁵⁴ Ashton {Day18/171:8-25}. In the event, Exova never told Studio E or Rydon that further work needed to be done on the Outline Fire Safety Strategy.

¶54.111 Issue 3 of the Outline Fire Safety Strategy was expressly incorporated into the Design & Build Contract between the TMO and Rydon.⁸⁵⁵⁸⁵⁵ Contract Documents for Enhancements and Improvements to Grenfell Tower, Schedule of Contract Information {TMO10041791/267} item 115. Although Mr Ashton was aware that a document of that kind would usually be provided to the main contractor for information at the tender stage, he was not specifically aware that in this case it had been incorporated into the building contract.⁸⁵⁶⁸⁵⁶ Ashton {Day18/172:6-14}.

¶54.112 Studio E also included Issue 3 of the Outline Fire Safety Strategy in the full plans application that was submitted to building control on 29 September 2014.⁸⁵⁷⁸⁵⁷ {SEA00000215}. Mr Ashton was not aware of that at the time, but he knew that it was standard practice to do so.⁸⁵⁸⁸⁵⁸ Ashton {Day18/172:15-22}. He also knew that it was unusual, when the work to a building was to include overcladding, for a fire safety strategy which did not deal with functional requirement B4 to be included in a full plans application.⁸⁵⁹⁸⁵⁹ Ashton {Day18/173:5-9}. He said that it would have been "nice" if the final version had contained such an analysis, but it had not been included because it had not been considered.⁸⁶⁰⁸⁶⁰ Ashton {Day18/173:11-14}.

¶54.113 Issue 3 of the Outline Fire Safety Strategy was produced at RIBA Stage E. According to Dr Lane, that was the time for the production of the final fire safety strategy which should have recorded the detailed proposals for the development, together with the promised analysis.⁸⁶¹⁸⁶¹ Lane {Day61/210:25}-{Day61/211:9}. However, Issue 3 did not represent any material advance on Issue 2 and Exova failed to produce any detailed and comprehensive fire safety strategy at any stage during the project.⁸⁶²⁸⁶² Lane, Phase 2 Report {BLARP20000017/225}, paragraph 6.12.12. In Dr Lane's opinion Issue 3 wholly failed to provide the fire safety design guidance required by the design team, the client and the contractor.⁸⁶³⁸⁶³ Lane {Day61/222:3-7}; Lane, Phase 2 Report {BLARP20000017/224} paragraph 6.12.2.

¶54.114 Despite having undertaken to provide a fire safety strategy for the refurbishment, Exova failed to complete the work in fundamental respects. Issue 3 represented nothing more than a stepping stone on the way to the production of the final document, as the paragraph dealing with functional requirement B4 made clear, and as a result, Exova failed to provide any guidance on the performance standards for the external wall. Dr Lane described that as a serious omission,⁸⁶⁴⁸⁶⁴ Lane {Day61/174:1-12}. but in truth it was more than that; it represented a fundamental failure by Exova to provide the services for which it had contracted. The fact that the reports were provided to the architect rather than the lay client does not excuse that failure. Although Studio E was at fault in failing to ask questions about the Outline Fire Safety Strategy in any of its forms, and particularly in failing to ask Exova to provide a concluded opinion on functional requirement B4(1), that does not excuse Exova for failing to seek the information needed to complete its work or make it clear that without it an essential part of the strategy was missing.⁸⁶⁵⁸⁶⁵ Lane {Day61/198:14}-{Day61/202:15}.

¶54.115 It was also of importance for Exova to draw attention to the fact that any insulation materials in the external wall should be of limited combustibility if the designers were following the guidance in paragraph 12.7 of Approved Document B. If that had been expressly stated, others engaged on the project, including Rydon and the TMO, might have thought twice about their choice of insulation. Again, the fact that others were unaware of that requirement does not exonerate Exova.

¶54.116 Mr Ashton sought to justify his failure to provide final advice in relation to functional requirement B4 by relying on Studio E's failure to provide him with detailed information about the overcladding. However, that does not excuse Exova's complete failure to deal with the requirements for the external wall. The project had been introduced to Mr Ashton as one which would include overcladding,⁸⁶⁶⁸⁶⁶ {EXO00000474}. he had attended at least one project team meeting (on 6 September 2012) at which the cladding had been discussed,⁸⁶⁷⁸⁶⁷ {ART00000404}. he had been sent minutes of other project team meetings referring to it⁸⁶⁸⁸⁶⁸ Meeting minutes dated 18 July 2012 {EXO00000753}, sent via email on 24 July 2012 {EXO00000751}. and he had been sent a number of work packages containing information about it.⁸⁶⁹⁸⁶⁹ {SEA00006394}; {SEA00006395}; Ashton {Day17/30:1-25}. At no stage, however, did he address his mind to the build-up of the external wall. Given his acknowledgement that the overcladding was, in his own words, "a fairly significant part of the design",⁸⁷⁰⁸⁷⁰ Ashton {Day17/49:2-14}. his failure to include it in the description of the project and his subsequent failure to consider that aspect of the refurbishment fell below the standards to be expected of a reasonably competent fire engineer. Something should have been included in the document to alert the designers to the need for careful consideration of functional requirement B4 in relation to the external wall and the peer reviews carried out before the production of all three issues of the strategy were defective in failing to identify that deficiency. That is so, even if each of them was understood at the time to be no more than an interim document.

¶54.117 None of the issues of the Outline Fire Safety Strategy contained any reference to the need for cavity barriers. When Mr Ashton prepared Issue 3 in November 2013 he had had his attention specifically drawn to the fact that there was to be a rainscreen cladding system in an email from Tomas Rek on 1 November 2013.⁸⁷¹⁸⁷¹ {EXO00000586}. That email ought to have alerted Mr Ashton to the need to address cavity barriers in the fire safety strategy, since it should have been clear to him that the design team needed his help in understanding the basic performance requirements for the external wall.⁸⁷²⁸⁷² {EXO00000586}; Lane {Day61/212:7}-{Day61/213:7}; Ashton {Day17/119:12}-{Day17/126:23}. In those circumstances we consider that Mr Ashton's failure to address cavity barriers and their locations fell below the standard of a reasonably competent fire engineer.⁸⁷³⁸⁷³ Lane {Day61/211:14}-{Day61/213:25}; Lane, Phase 2 Report {BLARP20000017/213} paragraph 6.9. Her views were unchanged after hearing the evidence of Exova's witnesses. Lane {Day61/222:22}-{Day61/223:1}.

Failure by Artelia to identify the omission

¶54.118 As employer's agent, Artelia was responsible for monitoring the performance of the contractor, Rydon, and reporting to the TMO.⁸⁷⁴⁸⁷⁴ {ART00005742/47} clause 1.1.4. It also had responsibility for establishing the roles and responsibilities of Rydon and specialist design subcontractors, confirming the scope of the building contract to the TMO and advising on additional works required by third parties.⁸⁷⁵⁸⁷⁵ {ART00005742/48} clause 1.3.3 and clause 1.3.5. It was not obliged to advise the TMO about specialist services required in connection with the project or about the design services needed under the building contract.⁸⁷⁶⁸⁷⁶ {ART00005742/47} clause 1.2.5 and clause 1.2.8. However, as administrator of the building contract it had an obligation to be aware of the appointment of specialist advisers and ensure that any work they had undertaken to perform was completed. Philip Booth accepted that Artelia's role as employer's agent included identifying any gaps in the completion of work.⁸⁷⁷⁸⁷⁷ Booth {Day49/151:3-7}; {Day50/83:18}-{Day50/84:21}.

¶54.119 It was apparent from the language of Issue 3 of the draft Outline Fire Safety Strategy that further work was required to complete it. Not only was it described as a draft, but it stated in terms that the effect of the proposed changes to the building in relation to the spread of fire over the external walls would be covered in a future issue. Philip Booth told us that he had read the tender documents in November 2013 and had recognised that there was more work to be done on the fire safety strategy, which he assumed would be carried out by Rydon.⁸⁷⁸⁸⁷⁸ Booth {Day 50/84:25}-{Day50/87:7}. Of itself, that was not remarkable and we accept that at the tender stage of a design and build contract, the fire safety strategy may not be fully developed.⁸⁷⁹⁸⁷⁹ Booth {Day50/86:18}-{Day50/87:7}. However, having recognised that there was further work to be done on it, the minutes of the contractor introduction meeting of 1 April 2014 taken by Artelia and checked by Mr Booth should not have recorded that Exova had completed the fire strategy at the tender stage.⁸⁸⁰⁸⁸⁰ {ART00002256/4} item 5.3. Regardless of whether it had mentioned the matter to Rydon, Artelia should have drawn the attention of the TMO to the fact that Exova's work had not been completed but failed to do so. At no time did Mr Booth or anyone else at Artelia alert the TMO to the need to ensure that the fire safety strategy had been completed by a suitably qualified fire engineer. The safety of the cladding was therefore never considered by a fire engineer.

Subsequent advice

¶54.120 During numerous meetings on the project between April and October 2014 Rydon expressed an intention to engage Exova as consultant fire engineer, as is formally recorded in the minutes of those meetings,⁸⁸¹⁸⁸¹ Minutes of Contractor Induction Meeting of 1 April 2014 {ART00002255/4}. Simon Lawrence said that he thought his understanding at the time had been that Rydon would engage Exova as a subcontractor. Lawrence {Day23/52:16}-{Day23/53:3}; The Pre-Start Meeting of 13 June 2014 {ART00002495/3}; Progress Meeting No. 1 held on 15 July 2014 {ART00002614/2}; Progress Meeting No. 3 held on 16 September 2014 {RYD00018299/2}; Progress Meeting No.2 held on 19 August 2014 {RYD00017870}.Show full note but no one on behalf of Rydon contacted Exova for that purpose.⁸⁸²⁸⁸² Lawrence {Day23/58:18-25}; Ashton {Day17/191:3-15}. In the event, Rydon did not appoint Exova as a consultant and there is no evidence that anyone from Exova attended any design team meetings after 6 September 2012. However, between 1 April 2014, when Rydon was proposed as principal contractor, and 24 March 2016,⁸⁸³⁸⁸³ {MAX00006093}. Exova continued to provide advice to Studio E, Rydon and its subcontractors⁸⁸⁴⁸⁸⁴ For example, advice to Neil Crawford on 18 September 2014 {EXO00000714} and {HAR00012077} and advice to David Hughes (Rydon) on 24 March 2016 {MAX00006094}. on aspects of fire safety and Mr Ashton was sent or copied in to at least 40 emails.

¶54.121 Rydon's attitude towards advice from Exova is evident from an email sent by Simon Lawrence to Neil Crawford on 19 September 2014. Mr Lawrence had noticed Exova's inclusion in an e-mail chain and had questioned its continued involvement in the project. He wrote: "I know that they provided information in the tender for KCTMO but I don't know if they are still working for them. I know that we haven't employed them. So if you are getting some free advice then great otherwise we will need to look at this."⁸⁸⁵⁸⁸⁵ {SEA00011754/1}. At this point, according to Simon Lawrence, Rydon had not decided whether a fire consultant was needed. It wanted to understand the strategy relating to the lower four floors before making a decision about the services they needed and wanted to obtain the views of building control, which it regarded as a "resource."⁸⁸⁶⁸⁸⁶ Lawrence {Day23/67:18}-{Day23/74:20}. During Progress Meeting No. 4 on 21 October 2014 Rydon again indicated that it would appoint a fire consultant⁸⁸⁷⁸⁸⁷ {RYD00022280}. and the item remained on the agenda because Artelia retained it as a matter calling for decision by Rydon.⁸⁸⁸⁸⁸⁸ Booth, {Day50/94:20-25}.

¶54.122 By the time of Progress Meeting No. 5 on 18 November 2014, however, the reference to Rydon's intention to appoint a fire consultant had disappeared from the minutes.⁸⁸⁹⁸⁸⁹ {ART00003150}. Claire Williams did not notice that⁸⁹⁰⁸⁹⁰ Williams {Day55/83:9}. and said she would have expected Artelia, as Employer's Agent, to pick it up.⁸⁹¹⁸⁹¹ Williams {Day55/79:10-14}; {Day55/80:4-10}; {Day55/81:1-11}. Philip Booth said that the usual practice was for an item to remain on the minutes until it had been completed or resolved and that he could not recall how that particular item had been allowed to disappear.⁸⁹²⁸⁹² Booth {Day50/95:20-23}.

¶54.123 Bruce Sounes recalled a conversation with Simon Lawrence in March or April 2014 during which Mr Lawrence had said that Rydon typically did not engage fire consultants on the basis that the fire safety strategy had been established by the client's team.⁸⁹³⁸⁹³ Sounes {SEA00014273/152} page 152, paragraph 372; Sounes {Day12/168:20}. Mr Lawrence did not recall that conversation,⁸⁹⁴⁸⁹⁴ Lawrence {Day23/62:24}. but agreed that it was a fair description of how Rydon typically dealt with such matters and did not quarrel with the substance of Mr Sounes' evidence, which we accept.⁸⁹⁵⁸⁹⁵ Lawrence {Day23/62:3-11}. He explained that Rydon did not normally engage fire consultants because it was building control's responsibility to raise any concerns over matters of that kind.⁸⁹⁶⁸⁹⁶ Lawrence {Day23/65:17-24}; {Day23/74:8-12}: he considered that Rydon "had a resource with building control."

¶54.124 Mr Lawrence told us that Rydon had been looking for advice from a fire safety consultant only in relation to the lower four floors of the tower, but he accepted that there was nothing in the documents to suggest that it had drawn any distinction for that purpose between the restructuring of the lower four floors and the installation of the cladding. We therefore think it unlikely that that distinction was present to Mr Lawrence's mind in 2014.⁸⁹⁷⁸⁹⁷ Lawrence {Day23/79:13}-{Day23/80:7}. He said that Rydon had made a positive decision not to appoint a fire safety consultant when it became clear that the lower four floors were not going to present a significant problem,⁸⁹⁸⁸⁹⁸ Lawrence {Day23/80:8-16}. but there was no evidence of when or how that decision was made or by whom. Stephen Blake told us that he and Simon Lawrence had decided not to appoint Exova as a consultant because it had already produced a fire safety strategy and because it was the responsibility of Studio E to make sure that it contained all the necessary information.⁸⁹⁹⁸⁹⁹ Blake {Day29/67:11-19}. We think it likely that Rydon decided not to engage Exova, or any other fire safety consultant because it did not think that it needed to do so in its own interests. Rydon did not tell the TMO or Studio E that it had decided not to appoint a fire consultant⁹⁰⁰⁹⁰⁰ Williams {Day55/84:2-10}. and it seems that the matter then disappeared from sight. Artelia and the

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¶TMO should both have been aware that Rydon had not appointed a fire consultant and

¶Artelia should have obtained a formal decision from Rydon and recorded it, together with the reasons for it, pursuant to its obligation to monitor Rydon's performance.

¶54.125 The failure to ensure the effective involvement of a fire engineer in the project following the appointment of Rydon as principal contractor was in our view one of the most serious flaws in the design and execution of the refurbishment. When Rydon was appointed as principal contractor the TMO continued to retain Exova, but neither the TMO nor Artelia appears to have understood clearly what services it was expected to provide or to whom. Artelia's duties included understanding where additional works by third parties were required. Artelia ought to have made it clear to the TMO that Exova's work had not been completed, that Rydon had not appointed anyone to finish it and that the TMO itself would therefore have to ensure that it was completed. For its part, the TMO, ought to have clarified Exova's position and ensured that the fire safety strategy was completed.

¶54.126 Mr Ashton understood that Exova's retainer had ended when Rydon was appointed as principal contractor and neither Rydon nor anyone else had asked it to continue acting.⁹⁰¹⁹⁰¹ Ashton {Day18/61:11-25}. Exova received no formal confirmation from the TMO that its services were no longer required, but Mr Ashton said that in his experience it was not unusual for Exova's services not to be retained in that situation.⁹⁰²⁹⁰² Ashton {EXO00001621/14} page 14, paragraph 5.9, We are surprised that Exova allowed client relations to be managed in such a casual manner, but the fact is that Mr Ashton never thought to ask for clarification of Exova's position, even though he was still being asked for advice on various matters from time to time on an ad hoc basis.⁹⁰³⁹⁰³ Ashton {Day18/64:3-7}. He thought that some members of the design team had assumed that Exova was still instructed; he certainly had taken no steps to disabuse them.⁹⁰⁴⁹⁰⁴ Ashton {Day18/141:9}-{Day18/142:6}.

¶54.127 Exova did not make a separate charge for their ad hoc advice but treated it as covered by the fee agreed with the TMO for RIBA Stages D and E.⁹⁰⁵⁹⁰⁵ {EXO00001204}; {EXO00001205}. Despite approving the invoices which Exova submitted to the TMO, it did not dawn on Claire Williams that Rydon had not appointed a fire consultant.⁹⁰⁶⁹⁰⁶ Williams {Day55/85:12-15}. Mr Ashton said that in his view the advice had not been provided under Exova's contract with the TMO, but was supplementary advice given on an ad hoc basis,⁹⁰⁷⁹⁰⁷ Ashton {Day17/184:16-25}. See also Ashton {EXO00001621/14} page 14, paragraph 5.10. but that is not reflected in the billing procedures.

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¶54.128 Exova gave significant ad hoc advice on two occasions: once in September 2014 and again in March 2015.

Advice in September 2014 (design of the cladding)

¶54.129 On 18 September 2014 Neil Crawford asked Mr Ashton for his comments on a request for information⁹⁰⁸⁹⁰⁸ {HAR00003616}; Email attaching the RFI {SEA00011703}. he had received from Harley about the location of horizontal fire breaks within the cladding.⁹⁰⁹⁹⁰⁹ {SEA00011705}. Harley thought that horizontal firebreaks might not be required between windows, because there was no "chimney effect" there. Mr Ashton replied that he had not seen details of what Studio E was doing to the external walls and asking for cross section or elevation drawings.⁹¹⁰⁹¹⁰ {RYD00018154}. At that stage he had not given any substantive consideration to the cladding or its implications for external fire spread.⁹¹¹⁹¹¹ Ashton {Day18/25:17-19}.

¶54.130 Later that day, in response to Mr Ashton's request, Mr Crawford sent him a number of drawings, including drawing number 1279 SEA (06) 120 which showed zinc outer cladding and contained a reference to thermal insulation alongside the code H92/776.⁹¹²⁹¹² {EXO00000710}, {EXO00000709}. That was the first time Mr Ashton had seen the design and specification for the cladding system.⁹¹³⁹¹³ Ashton {Day18/31:15-22}.

¶54.131 The code H92/776 referred to a paragraph in the NBS Specification⁹¹⁴⁹¹⁴ {SEA00000169/73}. which specified Celotex FR5000 insulation. Mr Ashton had not seen the Employer's Requirements or the NBS Specification⁹¹⁵⁹¹⁵ Ashton {Day18/127:7-8}. and did not ask to see them.⁹¹⁶⁹¹⁶ Ashton {Day18/31:1-14}. The code meant nothing to him⁹¹⁷⁹¹⁷ Ashton {Day18/29:11-22}. and he did not understand that the drawings included references to the materials to be used for insulation.⁹¹⁸⁹¹⁸ Ashton {EXO00001621/15} page 15, paragraph 5.17; Ashton {Day18/29:16-22}. Drawing number 1279 SEA (06) 120 also referred to "aluminium composite TBC", but, despite not being familiar with composite materials, Mr Ashton did not ask what that meant. He said that he had not looked at the drawings in any detail because Exova was no longer part of the design team.⁹¹⁹⁹¹⁹ Ashton {Day18/30:1-10}. In those circumstances he was not spending a lot of time on the project, although, as he accepted, he had not made that clear to Studio E.⁹²⁰⁹²⁰ Ashton {Day18/30:1-15}; {Day18/33:1-7}.

¶54.132 Having received the drawings from Studio E, Mr Ashton responded by saying that if the insulation in the cavities behind the rainscreen was combustible it would be necessary to provide cavity barriers as shown in drawing number 1279 (06) 120 in order to prevent fire from spreading from a flat to the one above, even if there was not a continuous cavity from the top of the building to the bottom.⁹²¹⁹²¹ {EXO00000708}. That advice was wrong insofar as it suggested that cavity barriers were required only if the insulation were combustible.⁹²²⁹²² Lane {Day62/44:16-25}. In order to comply with Approved Document B cavity barriers were required around the windows and at the top of the walls, regardless of the type of insulation used.⁹²³⁹²³ Lane {Day62/45:7-15}. He also failed to point out that in a building of over 18 metres in height the insulation should be of limited combustibility in order to comply with paragraph 12.7 of Approved Document B. Mr Ashton accepted that his response could have been more clearly worded⁹²⁴⁹²⁴ Ashton {Day18/39:1-18}. but in our view that suggests that he had not understood the significance of the nature of the insulation.

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¶54.133 The drawings provided to Mr Ashton by Studio E⁹²⁵⁹²⁵ In particular, drawing 1279 (06) 120{EXO00000710}. also showed horizontal cavity barriers only between the windows and not around the window frames. He did not notice that omission, despite his understanding that Approved Document B contained clear guidance on the importance of cavity barriers around windows.⁹²⁶⁹²⁶ Ashton {Day18/42:4-18}. He said that that was not the question he was being asked and that he had just wanted to know in broad terms what they were doing.⁹²⁷⁹²⁷ Ashton {Day18/41:10-25}. He said he had not asked for full details of the construction in order to do hours of work for which he would not be paid.⁹²⁸⁹²⁸ Ashton {Day18/40:10-13}; {Day18/41:16-25}-{Day18/42:1-3}; {Day18/42:19-24}; {Day18/43:15-21}. He had not seen that as part of his responsibility.⁹²⁹⁹²⁹ Ashton {Day18/42:19}-{Day18/43:5}.

¶54.134 Later the same day Neil Crawford sent another email to Mr Ashton⁹³⁰⁹³⁰ {SEA00011724}. attaching a datasheet for Celotex RS5000.⁹³¹⁹³¹ {RYD00018155}. He asked whether Daniel Anketell-Jones was right in thinking that, because the insulation was rated Class 0, cavity barriers were not required around the windows. Mr Ashton did not open the attachment and therefore did not read the datasheet.⁹³²⁹³² Ashton {Day18/46:15-23}; {Day18/47:3-19}; {Day18/49:1-8}; {Day18/55:6-8}. That was a serious error on his part. A reasonably competent fire engineer would have done so and, having read the datasheet, would have explained to Mr Anketell- Jones that Class 0 did not denote limited combustibility.⁹³³⁹³³ Lane, Phase 2 Report {BLARP20000017/279}; Lane, {Day62/49:11}-{Day62/50:8}. Mr Ashton said that he had not seen any need to open the attachment, since he had just been dealing with an exchange of emails about whether using a Class 0 material meant that cavity barriers were not required. If it had been necessary for him to look at it, he would have expected Mr Crawford to make some express reference to it.⁹³⁴⁹³⁴ Ashton {Day18/46:17}-{Day/47:11}. Mr Ashton was aware of the Celotex insulation product in general and, although he had never had cause to investigate it, he knew that it was a PIR foam and therefore combustible⁹³⁵⁹³⁵ Ashton {Day18/67:11-15}., even if he did not know how exactly it reacted to fire.⁹³⁶⁹³⁶ Ashton {Day18/48:1-17}; {Day18/56:12-17}. Despite having been sent the datasheet, however, at no stage did he ask himself whether Celotex RS5000 was suitable for use on the tower; indeed he maintained in evidence that he had not known that it was being used.⁹³⁷⁹³⁷ Ashton {Day18/53:21-25}-{Day18/54:1-5}. He said that, if he had been told that Celotex was to be used, he would have said that it was not acceptable for use on the building without test evidence.⁹³⁸⁹³⁸ Ashton, {Day17/96:1-3}; {EXO00001775/2} page 2, paragraph 2.3; See also Ashton {Day18/135:4-10} Mr Ashton said he would have carried out investigations if he had known that Celotex insulation was being used in the external walls. It did not occur to him to ask Mr Crawford what type of rainscreen cladding panel was being proposed⁹³⁹⁹³⁹ Ashton {Day18/69:2}. or to tell him that the Outline Fire Safety Strategy needed to be revised.⁹⁴⁰⁹⁴⁰ Ashton {Day18/69:11-18}.

¶54.135 Mr Ashton's response to the question posed to him was therefore directed solely to whether the use of Class 0 insulation obviated the need for cavity barriers in certain locations. He said:

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"A material which has a Class 0 rating is not necessarily non-combustible although the reverse is invariably true. Some Class 0 products will burn when exposed to a fully developed fire. In any case, you need to prevent fire spread from one flat to the flat above as I stated in my earlier email. What isn't clear from the information to hand is whether or not there is a continuous cavity from top to bottom in any part of the cladding (apart from around the column casings) irrespective of the type of insulation."⁹⁴¹⁹⁴¹ {EXO00001430}.

¶No one responded to his comment about the extent of the external wall cavity and he did not press for further information.⁹⁴²⁹⁴² Ashton {Day18/59:5-22}.

¶54.136 According to Dr Lane, industry awareness of the dangers presented by combustible materials was evolving rapidly at that time and by September 2014 Exova ought to have been aware of the third edition of BR 135 published in 2013 and BCA Technical Guidance Note 18 Issue 0 dated June 2014 (and published in August 2014), including the warnings they contained about the use of combustible insulation.⁹⁴³⁹⁴³ Lane {Day62/53:12}-{Day62/56:6}; {Day61/203:6-11}. It ought also to have been aware by that time of a number of cladding fires that had occurred in other countries, demonstrating the dangers posed by the use of combustible materials.⁹⁴⁴⁹⁴⁴ Lane {Day61/202:21}-{Day61/203:5}. Mr Ashton had already received indications from a number of sources that Celotex RS5000 was being proposed for use on the tower⁹⁴⁵⁹⁴⁵ In the Stage C Report, the link sent to him on 31 October 2012 {ART00008396}, and the datasheet sent to him for RS5000 {SEA00011724}. but had apparently failed to absorb the information. If he had opened the datasheet and obtained advice from colleagues in Warrington with specialist knowledge of materials⁹⁴⁶⁹⁴⁶ Ashton {Day17/93:9-14}. and their reaction to fire, it is likely that he would have alerted the design team to the risks involved.

¶54.137 Although at that time the drawings still specified zinc rainscreen panels, Dr Lane was clear that Mr Ashton should have known that the insulation did not comply with the guidance contained in Approved Document B and that cavity barriers were missing.⁹⁴⁷⁹⁴⁷ Lane {Day62/56:15-19}. She said that they were "red flags" which should have prompted him to consider how the external wall was being assessed and how it could comply with functional requirement B4.⁹⁴⁸⁹⁴⁸ Lane {Day62/52:16-22}; {Day62/56:15-19}.

¶54.138 Mr Crawford said that he had spoken to someone from Exova on 17 or 18 September 2014 to confirm the compliance of the Celotex insulation.⁹⁴⁹⁹⁴⁹ Crawford {Day9/176:23}-{Day9/177:11}. Mr Ashton did not recall any such conversation at about that time, nor could he recall ever having discussed with Mr Crawford Celotex insulation or its compliance.⁹⁵⁰⁹⁵⁰ Ashton {Day18/71:3-19}; Ashton {EXO00001775/2-5} page 2-5, paragraphs 2.2-2.3 and paragraphs 3.8-3.9}; Ashton {Day18/72:13}-{Day18/74:17}. Mr Crawford said that Exova had been emphatic that it was appropriate to use Celotex,⁹⁵¹⁹⁵¹ Crawford {Day10/58:1}-{Day10/59:1}. an assertion which Mr Ashton equally unequivocally denied.⁹⁵²⁹⁵² Ashton {Day18/72:14}-{Day18/74:14}; Ashton {EXO00001775/2} pages 2, paragraphs 3.3-3.5. Mr Crawford also told us that at about the same time he had told Mr Ashton that ACM panels were to be used on the building.⁹⁵³⁹⁵³ Crawford {Day10/91:16}-{Day10/92:11}. Again, Mr Ashton denied that. He did not recall ever having discussed with Mr Crawford the use of ACM panels generally or Reynobond 55 PE panels in particular.⁹⁵⁴⁹⁵⁴ Ashton {Day18/76:1-14}; Ashton {EXO00001775/2} page 2-4, paragraphs 2.5-2.6 and paragraphs 3.6-3.7. Neil Crawford said that Mr Ashton had understood the wall build-up⁹⁵⁵⁹⁵⁵ Crawford {Day10/94:1-22}; Ashton {Day18/77:5-21}. and had discussed with him the suitability of the cavity barrier strategy.⁹⁵⁶⁹⁵⁶ Crawford {Day10/94:1-22}. Mr Ashton also denied that.⁹⁵⁷⁹⁵⁷ Ashton {Day18/74:18}-{Day18/77:24}, {Day18/124:11}-{Day18/125:6}; Ashton {EXO00001775/3} page 3, paragraphs 3.1-3.2.

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¶54.139 Mr Crawford said that his understanding of the basis on which the cladding system was considered to be compliant with Approved Document B had been derived from conversations he had had with Exova sometime around 18 September 2014.⁹⁵⁸⁹⁵⁸ Crawford {Day9/179:5-7}. Mr Ashton did not recall any such conversation.⁹⁵⁹⁹⁵⁹ Ashton {Day18/78:7-9}. Mr Crawford also said that he recalled Mr Ashton's mentioning that the fire safety strategy would need to be revisited and completed,⁹⁶⁰⁹⁶⁰ Crawford {Day10/95:22}-{Day10/96:10}; {Day11/169:23}-{Day11/170:5}. which again Mr Ashton denied.⁹⁶¹⁹⁶¹ Ashton {Day18/78:10-20}. Mr Crawford went on to say that at about the end of March 2015 Exova had given him the impression that the proposed cladding system was acceptable and created no risk of external fire spread and that therefore there was no need for a further report.⁹⁶²⁹⁶² Crawford {Day11/181:20}-{Day11/183:15}. Mr Ashton also denied that.⁹⁶³⁹⁶³ Ashton {Day18/79:3-5}.

¶54.140 There was, therefore, in these respects a direct conflict between the evidence of Mr Ashton and that of Mr Crawford, both in relation to Exova's acceptance of the use of Celotex insulation and in relation to its recognition of the need for the work on the Outline Fire Safety Strategy to be completed in relation to functional requirement B4. Having considered their evidence carefully, we think that the evidence of Mr Ashton is the more reliable. The discussions, if they had occurred, would have been of considerable significance and would have merited confirmation by email, if not more formally. However, there is no reference to them in any of the contemporaneous documents, nor did Mr Crawford refer to them in the very full statement he made in November 2018.⁹⁶⁴⁹⁶⁴ Crawford {SEA00014275}. Mr Ashton may have adopted a casual approach to the Outline Fire Safety Strategy, but his failure to complete the section dealing with functional requirement B4 reflected a lack of positive instructions from Studio E. He was aware of the importance that would inevitably be attached to any opinion expressed by Exova on matters of that kind and could be expected to have put in writing any advice of that kind. Whatever may have passed between them, we are unable to accept that Mr Ashton gave the assurances described by Mr Crawford in what could only have been the most informal manner. If Mr Crawford had thought that that was his intention, he would surely have confirmed the conversation in an email to ensure that there had been no misunderstanding.

¶54.141 The exchanges that took place in September 2014 between Studio E and Exova occurred at a critical moment in the life of the project. The design team was asking important questions relating to the safety of the external wall and its compliance with the statutory guidance that were not answered in the current version of the Outline Fire Safety Strategy.⁹⁶⁵⁹⁶⁵ Lane, {Day62/49:11-19}; {Day62/60:4}-{Day62:61:20}; {Day62/52:16-22}; {Day62/56:15-19}. All those involved in the exchanges, including Exova, should have realised that the sections of the strategy relating to functional requirements B3 and B4 needed to be completed and that detailed and definitive guidance was required. Even if Mr Ashton could not complete that work without further information, at the very least he should have warned the project team and the TMO, his client, that important work was outstanding and that the current version of the strategy was materially incomplete. We can see no good reason why he did not do so and are satisfied that in failing to do so he fell short of the standard required of a reasonably competent fire engineer.

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Advice in March 2015 (cavity barriers and fire stopping)

¶54.142 On 3 March 2015 Mr Crawford asked Mr Ashton for advice on "fire breaks" at Grenfell Tower,⁹⁶⁶⁹⁶⁶ {EXO00001315}. attaching Harley's Specification Notes⁹⁶⁷⁹⁶⁷ {EXO00001319}. which referred to Reynobond rainscreen cassettes. Mr Ashton did not respond to that email and is unlikely to have read it at the time.⁹⁶⁸⁹⁶⁸ Ashton {Day18/83:16-23}; Ashton {EXO00001621/17} page 17, paragraph 5.25. He said that if he had read the Specification Notes, he would have drawn Studio E's attention to the fact that the use of Styrofoam in the window infill panels would not be acceptable to building control because it was combustible.⁹⁶⁹⁹⁶⁹ Ashton {EXO00001621/17} page 17, paragraph 5.27(c).

¶54.143 On 27 March 2015 Mr Crawford sent an email to John Hoban of RBKC building control, with a copy to Mr Ashton,⁹⁷⁰⁹⁷⁰ {EXO00001434}. asking for confirmation that a proposal for cavity barriers put forward by Ricky Kay of Siderise was acceptable. That appears to have been the first time that Mr Ashton had been copied in to an e-mail about the cladding sent to building control.⁹⁷¹⁹⁷¹ Ashton {Day18/92:10-17}. He was not concerned by the reference to rainscreen aluminium cassettes, as he was aware that aluminium was used in a variety of applications, and did not understand the term "cassettes".⁹⁷²⁹⁷² Ashton {Day18/92:21-22}. He did not take in the fact that aluminium rather than zinc was now being proposed.⁹⁷³⁹⁷³ Ashton {Day18/93:3-6}. In Dr Lane's view, this correspondence should have prompted Mr Ashton to ask for the information he needed to complete the Outline Fire Safety Strategy,⁹⁷⁴⁹⁷⁴ Lane, {Day62/52:4-12}; {Day62/61:5-11}; {Day62/62:20-24}. but regrettably it did not do so.⁹⁷⁵⁹⁷⁵ Ashton {Day18/93:7-11}.

¶54.144 Earlier that month a disagreement had broken out within the design team over whether fire stopping or cavity barriers were required in the cladding at the level of compartment floors between the internal structure and the rainscreen panels. On 30 March 2015 Mr Ashton was copied in to an email from Mr Hoban to various employees of Siderise, Harley and Rydon,⁹⁷⁶⁹⁷⁶ {EXO00000715/2}. in which he said that he interpreted Diagram 33 of Approved Document B as requiring fire stopping of the same fire resistance as the compartment floor (in this case 120 minutes) rather than a cavity barrier. On 31 March 2015 Mr Crawford sought Mr Ashton's advice, saying that he could not see any reference to that element of the design in the fire safety strategy.⁹⁷⁷⁹⁷⁷ {EXO00000715}. Mr Ashton responded the same day,⁹⁷⁸⁹⁷⁸ {EXO00000715}. saying that it was not something that would necessarily form part of a fire safety strategy for a building (although when he gave evidence he accepted that that had been wrong, because advice on the provision of cavity barriers would normally be part of any fire strategy for a building that was to be overclad).⁹⁷⁹⁹⁷⁹ Ashton {Day18/95:20-25}-{Day18/96:1-9}; {Day18/96:21-25}; {Day18/99:4-9}; Ashton {EXO00001621/19} page 19, paragraph 5.29 (F). He also expressed the view that only a cavity barrier was required in that location, since fire stopping would not stay in place in a fire, which would cause the zinc cladding to fail.⁹⁸⁰⁹⁸⁰ {EXO00000715}.

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¶54.145 Mr Ashton's cursory reading of the email chain was remarkably casual, given that he had been specifically asked to comment on the history of the discussion and to look at the correspondence in the chain below.⁹⁸¹⁹⁸¹ {EXO00001434/2}. His failure to read down the short chain also meant that he failed to notice the reference to aluminium cladding cassettes and continued to labour under the misapprehension that the rainscreen panels would be composed of zinc.⁹⁸²⁹⁸² Lane {Day62/63:24}-{Day62/64:8}. If he had included in the Outline Fire Safety Strategy the minimum requirements in Approved Document B for satisfying functional requirement B4, those questions might not have arisen. Moreover, the design team might have been alerted to the need to analyse in more depth the choice of materials for use in the external wall of the tower.

¶54.146 In Dr Lane's opinion, this correspondence demonstrated exactly the problem caused by a failure on the part of a fire engineer to express minimum performance requirements in clear terms.⁹⁸³⁹⁸³ Lane {Day62/60:3-10}. In her view, the sections of the detailed fire safety strategy relating to functional requirements B3 and B4 should have answered those questions, given that there was clearly confusion within the design team about the difference between fire stops and cavity barriers. In this case there was a need for the fire engineer to explain what they were, what they were for, and where they needed to be incorporated into the building.⁹⁸⁴⁹⁸⁴ Lane {Day62/60:23}-{Day62/61:4}. She considered that those and some later exchanges with the design team in September 2014⁹⁸⁵⁹⁸⁵ Lane {Day62/73:4-23}. should again have led Mr Ashton to realise that the fire safety strategy needed to be revised.⁹⁸⁶⁹⁸⁶ Lane, Phase 2 Report {BLARP20000017/255} paragraph 8.2.10. In relation to additional correspondence in October 2014 {EXO00001441} Dr Lane said that it would have been perfectly normal professional practice to have suggested updating the fire safety strategy. Lane {Day62/77:5-14}. As an absolute minimum he should have drawn attention to the fact that it was incomplete and asked for confirmation that he could complete it.⁹⁸⁷⁹⁸⁷ Lane, {Day62/61:6-11}.

¶54.147 At the time Mr Ashton did not know what type of cavity barrier had been proposed for use in the refurbishment. He did not ask the design team, since he thought that the information would be provided as part of the description of the cladding, which in the event Exova did not receive.⁹⁸⁸⁹⁸⁸ Ashton {Day18/100:19-21}. His reference to zinc cladding is surprising, given that he had been sent information only a few days earlier which had included reference to the fact that aluminium rainscreen cassettes were to be used,⁹⁸⁹⁹⁸⁹ {EXO00000715/4}. but he appears to have thought from start to finish that the rainscreen would be zinc. Mr Crawford said that he had told Mr Ashton in an email that the panels would be made of ACM,⁹⁹⁰⁹⁹⁰ Crawford {Day10/159:22}-{Day10/162:4}. but no such email has come to light and Mr Crawford's response to Mr Ashton did not refer to the nature of the rainscreen material.

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¶54.148 Throughout the exchange Mr Ashton was careful to confine himself to the questions asked of him,⁹⁹¹⁹⁹¹ Ashton {Day18/111:4}; {Day18/118:21}-{Day18/119:2}. focusing solely on the individual components of the external wall rather than on the wall as a whole.⁹⁹²⁹⁹² Ashton {Day18/131:2-4}. He did not notice that the drawing⁹⁹³⁹⁹³ {SEA00002499}. attached to Mr Crawford's email of 31 March 2015⁹⁹⁴⁹⁹⁴ {SEA00013044}. showed cavity barriers only at the head of the window, because he did not look at it at the time.⁹⁹⁵⁹⁹⁵ Ashton {Day18/123:7-15}. He did not identify the locations where cavity barriers were required in the external wall and he did not identify the performance criteria for the external wall set out in section 12 of ADB.

¶54.149 Mr Ashton said that his reference to the failure of the rainscreen in the event of a fire reflected his understanding that, although debris would fall from the building, the fire would not spread externally through the cladding as zinc is non-combustible.⁹⁹⁶⁹⁹⁶ Ashton {Day18/104:10-14}. See also Ashton {EXO00001621/19} page 19, paragraph 5.30: "My email was trying to explain that if a fire were to occur with external flaming, it would take some of the cladding panel with it, and this might cause the fire stop to fall away with it (this would of course depend on precisely how the fire stop was fixed)." In his written statement⁹⁹⁷⁹⁹⁷ Ashton {EXO00001621/3} page 3, paragraph 3.6. he said that producing a fire safety strategy does not normally involve advising on whether the use of a specific product would be satisfactory, but when giving evidence he agreed that, if the fire strategy consultant knew what kind of rainscreen panel the designer proposed to use, it would be essential to consider its flammability.⁹⁹⁸⁹⁹⁸ Ashton {Day17/91:8-13}.

¶54.150 Mr Ashton said that it did not occur to him in late March 2015 to revise the Outline Fire Safety Strategy because nothing he had seen had given him any cause for concern. He had not realised that the designers had been planning to use unsuitable materials.⁹⁹⁹⁹⁹⁹ Ashton {Day18/109:16-23}. In any event, although it had been in his mind that he might need to revise it in due course,¹⁰⁰⁰¹⁰⁰⁰ Ashton {Day18/120:1-3}. he still did not have enough information from Studio E to enable him to do that.¹⁰⁰¹¹⁰⁰¹ Ashton {Day18/119:24-25}. He accepted however that a reasonably competent fire engineer should have informed his client that the outstanding work on the Outline Fire Safety Strategy needed to be completed now that further information had become available about the design of the external wall and the choice of materials.¹⁰⁰²¹⁰⁰² Ashton {Day18/130:16-23}. He said he had not done that because he had been concentrating on the specific question raised in the email, which had been concerned with individual components of the external wall rather than with the wall as a whole.¹⁰⁰³¹⁰⁰³ Ashton {Day18/131:1-4}. Overall we were unimpressed by Mr Ashton's narrow approach.

¶54.151 On 31 March 2015, two minutes after Mr Ashton had sent his email to Mr Crawford, he received an email from Dr Pearson on the same point.¹⁰⁰⁴¹⁰⁰⁴ {EXO00001347}. Mr Ashton did not recall having received it¹⁰⁰⁵¹⁰⁰⁵ Ashton {EXO00001621/20} page 20, paragraph 5.32. and Dr Pearson could not recall why he had been sent it, but thought it might have been in response to a request for advice from Mr Ashton.¹⁰⁰⁶¹⁰⁰⁶ Pearson {Day19/146:14-19}; {Day19/147:11-16}. Mr Ashton thought that it had probably been sent because he had asked Dr Pearson for his opinion on the question that had been put to him.¹⁰⁰⁷¹⁰⁰⁷ Ashton {Day18/116:1-6}.

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¶54.152 Dr Pearson's email read as follows:

"We note that the barrier against fire spread between floors is provided through the connection of the structural floors to the existing external walls. The existing external walls are expected to provide sufficient fire resistance to prevent fire from entering the cavities at or near floor or ceiling level. We would not rule out that fire could enter the cavity if there is flaming through the windows. However, if significant flames are ejected from the windows, this would lead to failure of the cladding system, with the external surface falling away and exposing the cavity, eliminating the potential for unseen fire spread. A standard cavity barrier should be sufficient to prevent fire spread between floors while there remains a cavity. In view of the above, we do not feel that there should be a need for a 2-hour rated fire break in the cavities along the lines of the compartment floors or walls."

¶54.153 The message thus drew more explicit attention to the risks posed to the cladding by fire than Mr Ashton had done in his response.

¶54.154 When he drafted that email Dr Pearson had still not been given any detailed information about the construction of the external wall.¹⁰⁰⁸¹⁰⁰⁸ Pearson {Day19/156:16}. He did not know what stage had been reached in the design process,¹⁰⁰⁹¹⁰⁰⁹ Pearson {Day19/157:3}. did not look back to the Outline Fire Safety Strategy,¹⁰¹⁰¹⁰¹⁰ Pearson {Day19/166:5-8}; {Day19/169:1-4}. did not check what materials it was proposed to use¹⁰¹¹¹⁰¹¹ Pearson {Day19/170:2-8}. and directed his mind only to the specific question asked of him.¹⁰¹²¹⁰¹² Pearson {Day19/158:16-23}; {Day19/164:15-18}. Dr Pearson accepted that, generally speaking, any fire safety strategy should have been updated to include an analysis of the factors affecting external fire spread¹⁰¹³¹⁰¹³ Pearson {Day19/169:15-17}. and that someone should have considered the materials being used in the external wall.¹⁰¹⁴¹⁰¹⁴ Pearson {Day19/159:6-19}.

¶54.155 The correspondence illustrates the confusion within the design team between cavity barriers and fire stops. It also demonstrates the failure of Mr Ashton and Exova to provide clear, coherent advice on the minimum relevant performance requirements for the external wall as a whole, including the identification of cavity barriers and the locations at which they should be fitted.

Subsequent emails

¶54.156 On 19 October 2015, Claire Williams and Terence Ashton exchanged a series of emails relating to the changes that had been made to the layout of the lower floors of the tower¹⁰¹⁵¹⁰¹⁵ {ART00004926}. and on 21 December 2015 Andrew Bridges of R J Electrics also sent an email to Mr Ashton and Dr Pearson referring to major changes to the lower four floors.¹⁰¹⁶¹⁰¹⁶ {MAX00006084/6}: "I'm not sure if you've been made aware but there have been some fairly major changes to the lower levels since you issued your last Fire Strategy document, Iss 03."

¶54.157 Those messages should have prompted Mr Ashton to review the Outline Fire Safety Strategy, but unfortunately it did not occur to him to do so.¹⁰¹⁷¹⁰¹⁷ Ashton {Day18/138:5-6}; {Day18/139:7-10}.

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Completing the Outline Fire Safety Strategy

¶54.158 We find it surprising that neither the TMO, nor Studio E nor Rydon ever pressed Exova to revise its drafts or produce a final version of either the Existing Fire Safety Strategy or the Outline Fire Safety Strategy. As a result of that, and as a result of Mr Ashton's failure to ensure that he obtained the information required to enable him to complete the task, Exova never did complete either of the two pieces of work on Grenfell Tower for which it had been retained.

¶54.159 In January 2016 the minutes of a Clerk of Works meeting recorded¹⁰¹⁸¹⁰¹⁸ {ART00006688/5}. that the fire strategy needed to be brought up to date in accordance with discussions on site. It was duly recorded as an action point for Rydon's site manager, David Hughes. Mr Ashton said that Mr Hughes had never asked for the fire strategy to be brought up to date.¹⁰¹⁹¹⁰¹⁹ Ashton {Day18/140:20}. Mr Hughes' said¹⁰²⁰¹⁰²⁰ Hughes {Day27/183:4-17}. that the minutes had not been referring to Issue 3 of the Outline Fire Safety Strategy but to the fire safety strategy drawings, which in due course had been updated.¹⁰²¹¹⁰²¹ {TMO10013339}; See also email from David Hughes to Neil Crawford requesting that the fire strategy drawing be updated. {RYD00082268}. That is not how the note reads, but Mr Hughes was at the meeting and must have been aware of the nature of the discussions.

CDM Regulations

¶54.160 It did not occur to Mr Ashton that a completed fire safety strategy for the building was needed for the purposes of the health and safety file required by the CDM Regulations.¹⁰²²¹⁰²² Ashton {Day18/139:11-15}.

¶54.161 Dr Pearson thought that in 2013 Exova was a "designer" within the meaning of the CDM Regulations,¹⁰²³¹⁰²³ Pearson {Day19/55:20-24}. although he could not remember how advanced his understanding of the regulations was at that particular time. Mr Ashton, on the other hand, told us that Exova generally took the view that when it was producing a fire safety strategy it was not a designer for the purpose of the CDM Regulations because it was simply applying regulations and guidance available in the public domain rather than creating something unique or original. For that reason the Fee Proposals did not refer to the CDM Regulations.¹⁰²⁴¹⁰²⁴ Terence Ashton did say that this view is changing "… in light of the fact that we sometimes design smoke extract systems and so possibly we need to look at that." Ashton, {Day16/120:1-25}. As explained earlier in this chapter, Exova's work on the fire safety strategies made it a "designer" under the CDM Regulations. It therefore had a duty to avoid foreseeable risks to the health and safety of any person liable to be affected by the refurbishment work.¹⁰²⁵¹⁰²⁵ CDM Regulations 2007, regulation 11. Mr Ashton should have appreciated that.

Overview

¶54.162 Exova's work on the Grenfell Tower project fell a long way short of the standard to be expected of a reasonably competent fire engineer. Its work was poorly resourced, casual and both incomplete and inaccurate in a number of important respects, all of which in our assessment contributed to the lack of proper attention to fire safety matters throughout the refurbishment project. Its unprofessional approach was characterised by Cate Cooney's email of 17 September 2012, in which she described how the proposals would make "a crap condition worse,"¹⁰²⁶¹⁰²⁶ {EXO00001279}. and by Mr Ashton's response to Dr Pearson's identification of a "rather fundamental"¹⁰²⁷¹⁰²⁷ Lane, Phase 2 Report {BLARP20000017/99} paragraph 4.7.81; Lane, {Day61/205:15}-{Day61/207:1}. non-compliance with statutory guidance, in which he expressed the hope that building control would not identify the problem.¹⁰²⁸¹⁰²⁸ {EXO00001444}. The latter comment revealed an approach to fire safety that we consider irresponsible.

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¶54.163 We entirely accept that Exova was badly briefed on the project and that others, particularly Studio E, Rydon, and the TMO, failed to take a proper interest in its work. Studio E failed to provide it with important information in a timely manner, particularly information about the overcladding of the tower. Rydon demonstrated a worrying lack of concern for fire safety, in particular, in failing to obtain a completed fire safety strategy for the project. It misguidedly assumed that it could rely on others (including building control) to identify any problems and failed to appoint a fire engineer, despite having said repeatedly over many months after its appointment as principal contractor that it intended to do so. Artelia and the TMO also overlooked the fact that the fire safety strategy was incomplete and that no fire engineer had been appointed to complete it. The TMO displayed a regrettable lack of interest in fire safety and a casual attitude to its responsibilities in that regard. Those are all matters which contributed to the unsatisfactory way in which Exova carried out its work. It is, in particular, astonishing that none of the other professionals appears to have realised or warned Rydon or the TMO that Exova's work on the Outline Fire Safety Strategy was incomplete in relation to the compliance of the external wall with functional requirement B4.

¶54.164 However, none of that can exonerate Exova. The very fact of its involvement in the project gave the design team and the TMO as the client a false sense of security and led some to believe that fire safety matters had been properly and comprehensively addressed.¹⁰²⁹¹⁰²⁹ For example, John Hoban of RBKC building control relied on the fact that Exova was working on the project when failing to scrutinise properly the external wall materials. Hoban {Day46/27:16-21}; {Day45/202:6}-{Day45/204:10}.

¶54.165 By far the most serious criticism of Exova is that a final version of the much-needed Outline Fire Safety Strategy was never produced and that it failed either to draw that fact to the attention of the design team or to warn it about the potential consequences, despite having numerous opportunities to do so. Exova's approach was to do the minimum required at the time and, when asked for advice, to adopt a narrow and blinkered approach to the questions it was asked. Consistently with that, Mr Ashton repeatedly failed to take action when he saw, or should have seen, that action was required. Dr Barker and Ms Cooney approached their work in a casual manner not consistent with its importance. None of the authors or reviewers of documents ever attended the site¹⁰³⁰¹⁰³⁰ Cooney, {Day14/72:24}-{Day14/73:1}; Dr Barker did not have time to carry out a site visit herself. Barker {Day15/119:17-24}; Terence Ashton did not visit the site "possibly because [he] had other priorities". Ashton {Day16/168:8-25}. and the only site visit carried out by James Lee lasted a mere two hours, which was far too short for a building of the size and condition of Grenfell Tower.¹⁰³¹¹⁰³¹ Lane {Day61/77:18}-{Day61/78:13}; Lane, Phase 2 Report {BLARP20000017/88} paragraph 4.7.14. Insufficient time was spent drafting the reports,¹⁰³²¹⁰³² For example, 15 hours was spent by Cate Cooney on the Existing Building fire strategy of August 2012. Phase 2 Report {BLARP20000017/87} paragraph 4.7.11; There is no evidence that Ms Cooney attended the site. Phase 2 Report {BLARP20000017/336} paragraph 14.1.19; For the Primary Refurbishment Project, 53 hours were invoiced for Primary Refurbishment project, 51.5 were Mr Ashton's. Phase 2 Report {BLARP20000017/90} at paragraph 4.7.23.Show full note fewer than three working days being spent on RIBA Stage C, less than a week on Stage D/E and no time at all recorded for work on Stage F.¹⁰³³¹⁰³³ {EXO00001353}. Exova's attitude was wholly inconsistent with the careful approach to matters affecting life-safety that was required on a project of this kind. One sees a similar attitude displayed in Mr Ashton's repeated failure to take the initiative, for example, by asking for missing information, obtaining and reading the RIBA Stage C and D reports and by regularly failing to open attachments to emails.

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¶54.166 Exova's casual approach is also demonstrated in the operation of its peer review process. Dr Barker's review of the Existing Fire Safety Strategy drafted by Ms Cooney was cursory, to say the least, and reviews which should have been undertaken by someone of an equal or greater seniority than the author¹⁰³⁴¹⁰³⁴ Ashton {Day17/171:4-6}, Ashton {EXO00001621/9} page 9, paragraph 4.7; Cooney {EXO00001590/3} page 3, paragraph 3.8; Ashton {Day17/174:8-11}. were in the case of the documents produced by Mr Ashton in fact undertaken by a more junior employee. We agree with Dr Lane that this was unacceptable and that the unsatisfactory nature of the process was demonstrated by the failure of any of Exova's reviewers to notice the inadequacies of paragraph 3.4.1 in relation to functional requirement B4.¹⁰³⁵¹⁰³⁵ Lane {Day61/209:24}-{Day61/210:7}. Exova's peer review procedure also applied to emails containing technical advice,¹⁰³⁶¹⁰³⁶ Pearson {EXO00001753/3} page 3, paragraph 3.7; Pearson {EXO00001753/6} page 6, paragraph 4.5; Ashton {Day17/177:1-9}. but there again it was not always followed. Dr Pearson said that Mr Ashton usually led by example,¹⁰³⁷¹⁰³⁷ Pearson {Day19/41:2-13}. but he does not appear to have followed the policy in the case of the Grenfell Tower project. One notable example is the email he sent to Mr Crawford on 31 March 2015,¹⁰³⁸¹⁰³⁸ {EXO00000715}. which was sent before he had received Dr Pearson's advice. There is nothing to suggest that the emails Mr Ashton sent on 18 September 2014 had been checked by anyone of equal or greater seniority.

¶54.167 Mr Ashton's cavalier approach to formal procedures was demonstrated in other ways. Exova purported to operate in accordance with the requirements of ISO 9001 and had produced a code of procedure called its "Overall Procedure Review",¹⁰³⁹¹⁰³⁹ {EXO00001209}. Issue 2 was issued on 18 December 2014 and became effective from 1 January 2015. which was designed to help staff meet the relevant standards. Mr Ashton was familiar with it¹⁰⁴⁰¹⁰⁴⁰ Ashton {Day17/161:6-19}. but he did not routinely follow it and did not do so in relation to the Grenfell Tower project. Instead he chose to follow procedures he had adopted on previous projects.¹⁰⁴¹¹⁰⁴¹ Ashton {Day17/163:3-25}. He said that he had not followed the procedure described in the "Overall Procedure Review" because the project had not proceeded in the usual way.¹⁰⁴²¹⁰⁴² Ashton {Day17/165:1-3}. That was unfortunate, because if he had followed the prescribed procedure, he would have had to check that all elements of the project had been completed satisfactorily.¹⁰⁴³¹⁰⁴³ {EXO00001209/4} paragraph 9. He did not do that, however, as he was still waiting for further information about the external wall. He did not contact either the TMO or Studio E to ask them whether the services Exova had provided matched their expectations.¹⁰⁴⁴¹⁰⁴⁴ Ashton {Day17/168:25}-{Day17/169:13}.

¶54.168 Mr Ashton himself had no formal training in fire engineering,¹⁰⁴⁵¹⁰⁴⁵ Lane Phase 2 Report {BLARP20000017/85} paragraphs 4.6.18-4.6.19. no previous experience of overcladding high-rise buildings,¹⁰⁴⁶¹⁰⁴⁶ Ashton {Day16/28:18}-{Day16/29:8}. and very little knowledge of cladding materials.¹⁰⁴⁷¹⁰⁴⁷ Ashton {Day17/76:20}-{Day17/77:6}; Ashton {Day18/86:5}-{Day18/89:25}. In those circumstances it is perhaps unsurprising that he failed to grasp the importance of ensuring that a thorough analysis was made of the proposals in so far as they affected functional requirement B4, but that in turn makes it difficult to understand why he was assigned to lead the project in the first place. In our view that was itself a fundamental mistake. If Exova had asked a fire engineer with experience of overcladding high-rise residential buildings to manage the project, the critical importance to fire safety of the components of the external wall might have been recognised. Mr Ashton was effectively unsupervised in this work. The only Chartered Fire Engineer involved in the project at Exova was Dr Barker, whose contribution to the work was negligible.¹⁰⁴⁸¹⁰⁴⁸ Lane Phase 2 Report {BLARP20000017/82} paragraph 4.6; Lane {Day61/51:1-25}.

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¶54.169 Neither Mr Ashton, Dr Barker, nor Dr Pearson thought that when drafting a fire safety strategy for a general needs block of flats they were required to consider means of escape for those with disabilities,¹⁰⁴⁹¹⁰⁴⁹ Lane {Day62/85:22}-{Day62/88:23}; Pearson {Day19/133:2}-{Day19/138:25}. despite the fact that Mr Ashton had been involved in the drafting of Part 8 of BS 5588-8:1999, Fire precautions in the design, construction and use of buildings – Part 8: Code of practice for means of escape for disabled people.¹⁰⁵⁰¹⁰⁵⁰ Ashton {Day18/2:19}-{Day18/3:12}; {BSI00000018}. Accordingly, neither the Existing Fire Safety Strategy, nor the Outline Fire Safety Strategy contained any reference to the characteristics of those who lived in the tower or the possibility of providing additional measures for those who needed help in evacuating. In that respect Exova again fell below the standard to be expected of a reasonably competent fire engineer as it overlooked the inclusive design guidance in Approved Document B on identifying additional measures which may be required to accommodate the needs of all persons with access to the building.¹⁰⁵¹¹⁰⁵¹ Lane {Day62/84:11}-{Day62/96:1}.

¶54.170 Exova's failure to identify the significant fire safety risks introduced by the refurbishment was not only inadequate but positively dangerous. In order to complete its work it should have identified the nature of the proposed rainscreen, and as a result its combustible nature, and also the unsuitability of the combustible insulation and window infill panels, as well as the absence of cavity barriers in key locations. We have therefore come to the view that Exova bears considerable responsibility for the fact that Grenfell Tower was in a dangerous condition on completion of the refurbishment.

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