Chapter 61: The Health and Safety File

Chapter 61: The Health and Safety File

¶61.1 As we have explained in Chapter 48, the CDM Regulations applied to the Grenfell Tower refurbishment: the CDM Regulations 2007 applied up to 6 April 2015; after that date the CDM Regulations 2015 applied. Both sets of regulations require the production of a health and safety file once construction works have been completed. Under the 2007 Regulations the duty to produce a health and safety file lay on Artelia as CDM co-ordinator. Under the 2015 Regulations, the duty lay on the TMO as principal designer.

¶61.2 Regulation 20(2)(e) of the 2007 Regulations required the CDM co-ordinator (Artelia) to review and update any existing health and safety file for the tower or, if one did not exist, to prepare one. If the 2007 Regulations had remained in force, Artelia would have been required at the end of the construction phase to pass the health and safety file to the TMO.^25112511 CDM Regulations 2007 {INQ00011315/11} Regulation 20(2)(f).

¶61.3 The health and safety file is an important document. It contains detailed information about work carried out on a building (whether by way of a new construction or refurbishment), including fire safety information. As Dr Lane explained in her evidence, it enables anyone carrying out work on a building to know what construction work has previously been done and, of particular relevance in this case, where fire safety features are located.^25122512 Lane {Day62/175:18}-{Day62/176:11}. She described it as part of the "golden thread" of information about the building, which, together with information produced pursuant to regulation 38 of the Building Regulations and the Fire Safety Order, is intended to be simple, easy to find and clear about what it contains.

¶61.4 There was no health and safety file for Grenfell Tower when the refurbishment began.^25132513 {RYD00092644/18} paragraph 3.14. Work had been carried out on the tower over the years but, for reasons we do not need to consider, no health and safety file had been produced.^25142514 Previous projects included improvements to the lifts and the replacement of fire doors. For more details see Lane, Health and Safety File Report {BLARP20000012}.

¶61.5 The Approved Code of Practice supporting the CDM Regulations 2007 advised that a CDM co-ordinator should make arrangements at the beginning of a project to collect and compile the information that is likely to be needed for the file and should have a discussion with the client about matters such as the format and type of information that should be obtained.^25152515 Approved Code of Practice L144 {INQ00013936/22-23} paragraph 79; Lane, Health and Safety File Report {BLARP20000012/106}, paragraph 9.7.15. The Approved Code of Practice also advised that the client (in this case the TMO) should make sure that the CDM co-ordinator compiled the health and safety file.^25162516 Approved Code of Practice L144 {INQ00013936/59} paragraph 261; Lane, Health and Safety File Report {BLARP20000012/106}, paragraph 9.7.17. Simon Cash, Artelia's project director, said that the information needed for the health and safety file was not always available until the end of a project and that he would therefore not have expected Artelia to produce a health and safety file until the end of the refurbishment.^25172517 Cash {Day49/80:22-24}; {Day49/81:7-13}. In his view that was normal practice, both on refurbishment projects and new construction projects.^25182518 Cash {Day49/80:10-25}. David Gibson, TMO's Head of Capital Investment, said that he had never been provided with a health and safety file before the end of the work.^25192519 Gibson {Day54/63:4-8}. As a result, contrary to the guidance contained in the Approved Code of Practice, Artelia did not start gathering information for a health and safety file at the beginning of the refurbishment. It was not until February 2015 that it started work to prepare a file and sought information from contractors working on the refurbishment.^25202520 {ART00003575}; {ART00006171}; {ART00009283}. On 21 April 2015, Claire Williams, the TMO's project manager, sent an email to Paul Burrows (who had taken over from Keith Bushell as CDM co-ordinator) asking him to check whether Artelia was up to date with compiling the health and safety file. Mr Burrows explained that Artelia had not received any information from contractors but that he did not think that was unusual and was expecting to receive information at the end of the project.^25212521 {ART00006299/1}.

Change from CDM co-ordinator to principal designer

¶61.6 The CDM Regulations 2015 brought about some substantive changes to the legislative regime. They included the abolition of the position of CDM co-ordinator and the introduction of a new position of principal designer, one of whose duties is to prepare a health and safety file appropriate to the characteristics of the project during the pre‑construction phase, to keep it up to date and to pass it to the client at the end of the work.^25222522 CDM Regulations 2015 {INQ00011316/12} Regulation 12(5), (6) and (10). Transitional provisions, which applied to the Grenfell Tower refurbishment, provided for the CDM co-ordinator to remain in position until a principal designer had been appointed or the project came to an end. They also imposed a duty on the client to appoint a principal designer by 6 October 2015.^25232523 CDM Regulations 2015 {INQ00011316/41-42} Schedule 4, paragraph 4. If the client failed to do so, it automatically became the principal designer itself.^25242524 CDM Regulations 2015 {INQ00011316/43} Schedule 4, paragraph 6(3).

¶61.7 On 2 February 2015, Keith Bushell sent an email to Nick Valente^25252525 Nick Valente was an assistant employer's agent employed by Artelia - Booth {ART00008527/3} page 3, paragraph 13. and Philip Booth^25262526 Philip Booth was brought into the project in April 2013 to assist his colleague at Artelia, Robert Powell, who was the employer's agent. By July 2013 he was acting as employer's agent – Booth {ART00008527/3} page 3, paragraph 12. informing them that, in light of the forthcoming change to the CDM Regulations, the TMO would have to appoint a principal designer.^25272527 {ART00009283}. The email was internal to Artelia and we have not seen any evidence that at that time Artelia told the TMO that it would need to appoint a principal designer.

¶61.8 On 20 July 2015, Neil Reed of Artelia^25282528 Neil Reed was employed as an employer's agent for Artelia from March 2015 – Reed {ART00006663/1} page 1, paragraph 2. sent an email to Claire Williams attaching a revised notice under the CDM regulations naming Artelia as the principal designer for the refurbishment.^25292529 This is known as the F10 Notice for CDM purposes. It is a formal notification sent to the Health and Safety Executive containing details of the project. It is required where a project is "notifiable". Under the CDM 2007 Regulations a project was notifiable if it was likely to involve more than 30 days or 500 person days of construction work, CDM Regulations 2007 {INQ00011315} Regulation 2(3) and 21; Similar provisions apply under the CDM Regulations 2015 {INQ00011316/7} Regulation 6.Show full note Claire Williams questioned whether Artelia should be a "designer" and on 21 July 2015, Colin James^25302530 Colin James was employed by Artelia as a CDM co-ordinator – James {MET00080879/4} page 4. of Artelia responded, explaining that the new CDM Regulations 2015 required the TMO to appoint a principal designer by 6 October 2015.^25312531 {ART00009321/2-4}. An internal email passing between employees of Artelia who were working on the refurbishment in July 2015 shows that they were aware that the TMO needed to be alerted to the change in the regulations.^25322532 {ART00009321/8} see email sent by Paul Burrows to Colin James on 13 July 2015 and {ART00009321/1-2} email sent by Neil Reed to Colin James and Paul Burrows on 21 July 2015. Claire Williams said that she had been expecting Artelia to become principal designer but that it had told her in late September 2015 that it would not do so because its professional indemnity insurance did not cover it. It is clear, however, from an internal email sent at around that time that Artelia was not willing to take on that role in any event.^25332533 Williams {TMO00853697/3} page 3, paragraphs 11-14; {ART00006344}; {ART00006195}. We note that following a progress meeting on 18 September 2015 Claire Williams was to appoint a principal designer from the TMO's consultancy framework and it therefore seems that she was at least aware of the need to appoint a principal designer before the end of September 2015.^25342534 {ART00004725/7} item 7.3.

¶61.9 In September 2015 Claire Williams contacted external consultants and professionals working on the project, including Rydon, to see whether they would take on the position of principal designer, but they all declined to do so.^25352535 Williams {TMO00853697/3} page 3, paragraph 15; {TMO00853697/4} page 4, paragraph 17; {ART00006174}; {ART00006195}; {ART00009336}; {ART00009342}. Ultimately, therefore, the TMO decided to take on the task itself on the basis of advice it had received, probably from Simon Cash of Artelia, that the design was "fundamentally complete".^25362536 Williams {TMO00853697/5} page 5, paragraph 21; Cash {ART00009416/7} page 7, paragraph 25. It took that decision on the basis that it would ask Rydon to complete the health and safety file.^25372537 {ART00009343}; {ART00005184/2-3} item 2.8; {ART00006735/2} item 2.8; Williams {TMO00853697/5} page5, paragraph 23. For the purposes of the CDM Regulations 2015, however, it was the obligation of the TMO as principal designer to prepare the health and safety file.^25382538 CDM Regulations 2015 {INQ00011316/12} Regulation 12(5), (6) and (10).

¶61.10 Under the 2007 Regulations, CDM co-ordinators were under an obligation to prepare or revise the health and safety file^25392539 CDM Regulations 2007 {INQ00011315/11} Regulation 20(2)(e). and pass it to the client at the end of the construction phase.^25402540 CDM Regulations 2007 {INQ00011315/11} Regulation 20(2)(f). Although we were told that CDM co-ordinators did not typically construct a health and safety file until the end of a project,^25412541 Reed {Day50/183:17-23}; Cash {Day49/86:1-5}; Booth {Day50/101:5-14}; Artelia Modules 1 and 2 Closing Submissions for Phase 2 {ART00009458/32} paragraphs 103-106. the Approved Code of Practice said that it should be compiled as the project progressed,^25422542 {INQ00013936/58-59} paragraphs 258-59. allowing for material to be gathered while it was fresh. Judging by the limited and largely irrelevant documents that Artelia had gathered by October 2015, it is clear that no meaningful progress had been made since the efforts in February and March 2015.^25432543 {ART00004949} listing the only information collected, being a site inspection report {ART00004950}; CDM Reports {ART00004951}; {ART00004952}; CDM Risk Register {ART00004953}; F10 notifications {ART00004954}; {ART00004955}; Email from Rydon {ART00004957} attaching method statement and phasing plans; phase drawings {ART00004958}; {ART00004960}; {ART00004961}; {ART00004962}; Project specific method statement {ART00006176}; Rydon email {ART00004963} attaching site-wide risk assessment {ART00004964}; site layout plan {ART00004965}; emergency plan {ART00004966}; traffic management plan {ART00004967}; site rules; Rydon email {ART00005015} attaching construction phase health and safety plan {TMO00869734}; Email confirming construction phase plan is adequate {ART00004971}.Show full note Artelia did not make up for the lack of progress before October 2015, even though it must have been clear in the preceding months that the TMO and any principal designer it appointed would have been greatly assisted by the marshalling of appropriate documents.

¶61.11 Claire Williams had been given short notice of the need to find a principal designer and the TMO was not given enough time to consider its options.^25442544 Williams {TMO00853697/4} page 4, paragraph 19. A number of emails sent at the time within Artelia show that some people, notably Mr Reed and Mr Cash, accepted that Artelia had not handled the transition to principal designer well.^25452545 {ART00009356}. However, the TMO was also to blame because it overestimated its own ability to review and scrutinise the health and safety file when it was produced (see further below). Neil Reed warned Claire Williams that if the TMO took on the role of principal designer, it would need someone to check the health and safety file and confirm that it was compliant. He offered to make someone available as a CDM adviser for that purpose^25462546 {ART00004824}; {ART00004865/4} item 4.2; {ART00009364}. but the offer was refused.

The health and safety file

¶61.12 Having been asked by the TMO to complete it, Rydon sub-contracted the preparation of the building manual for the refurbishment to a company called All Group Holdings Ltd.^25472547 Butler {MET00012822}. In addition to its work on the building manual, All Group Holdings gathered information for inclusion in the health and safety file and produced a three-page document containing cross-references to parts of the building manual. All Group Holdings sent the document to Rydon, describing it as its proposals for the health and safety file.^25482548 {RYD00080302}; {TMOM00001932}. The guidance describing the information that should be contained in a health and safety file has not materially changed since 1994.^25492549 Lane {Day62/178:18-23}; Lane, Phase 2, Health and Safety File Report {BLARP20000012/47-51} paragraphs 5.7.14 – 5.7.19 and Table 5.1; "Managing health and safety in construction, Construction (Design and Management) Regulations 2015, Guidance on Regulations" at Appendix 4 {HSE00000003/81-83}. The recommended contents include (among other things) (1) a brief description of the work carried out, (2) residual hazards and how they have been dealt with, (3) the nature, location and markings of significant services, including fire-fighting services and (4) information about, and as-built drawings of, the structure, its plant and equipment.^25502550 Lane, Phase 2, Health and Safety File Report {BLARP20000012/48} paragraph 5.7.14-5.7.16.

¶61.13 Claire Williams had received some training on the CDM Regulations and was familiar in general terms with what a health and safety file should contain.^25512551 Williams {Day56/119:22}-{Day56/120:9}. She accepted that she would have needed help to assess the quality of the health and safety file provided by Rydon but she did not specifically ask Artelia for guidance.^25522552 Williams {Day56/120:11}-{Day56/122:25}. She checked the health and safety file, but we got the impression that, although she identified some gaps and missing information, she did not make a serious effort to ensure that the defects were made good.^25532553 Williams {Day56/142:12}-{Day56/144:21}.

Dr Lane's evidence

¶61.14 Dr Lane prepared a report on the health and safety file and gave evidence to the Inquiry during Module 1.^25542554 Lane, Phase 2, Health and Safety File Report {BLARP20000012}; Lane {Day62/166:2}-{Day62/202:25}. Her report contained a thorough analysis of the contents of the health and safety file presented to the TMO by Rydon and identified where information was missing, inaccurate or incomplete.^25552555 Lane, Phase 2, Health and Safety File Report {BLARP20000012/144} paragraph 10.5.5. Her particular criticisms of the health and safety file, which we accept, were that it did not enable the persons responsible for any work on Grenfell Tower to understand the condition of the building and the hazards and risks arising from the refurbishment.^25562556 Lane, Phase 2, Health and Safety File Report {BLARP20000012/145} paragraph 10.5.8; Lane {Day62/196:4}-{Day62/199:17}; {Day62/202:20-25}. Nobody sought to challenge Dr Lane's evidence, which was to a large extent limited to the contents of the documents.

¶61.15 We are satisfied that the health and safety file did not contain the information referred to in the relevant guidance and was not presented in a form that made it readily usable. The TMO failed to ensure that the file was properly organised and contained accurate and up to date information about the refurbishment. Overall, it was incomplete, confusing and thoroughly unhelpful.

¶61.16 During her evidence Dr Lane was asked whether the health and safety file should have been available on the night of the fire to assist the fire brigade. Her view was that drawings containing basic information about the building should have been available rapidly.^25572557 Lane {Day62/206:25}-{Day62/208:11}. She was unwilling to speculate about what might have happened if a complete health and safety file had been available on the night of the fire^25582558 Lane {Day62/208:13-23}. and we express no view on the matter.